Provider Demographics
NPI:1427185941
Name:HAUCK, MARY ELLEN (PTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ELLEN
Last Name:HAUCK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1028 ULMSTEAD CIR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MD
Mailing Address - Zip Code:21012-1639
Mailing Address - Country:US
Mailing Address - Phone:410-757-1413
Mailing Address - Fax:
Practice Address - Street 1:140 STEPNEY LN
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2801
Practice Address - Country:US
Practice Address - Phone:410-956-3559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA2486225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDA2486OtherPT ASSISTANT LICENSE