Provider Demographics
NPI:1437466224
Name:GIVEN, MARY JO (MS,PT)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:GIVEN
Suffix:
Gender:F
Credentials:MS,PT
Other - Prefix:
Other - First Name:JO
Other - Middle Name:
Other - Last Name:GIVEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS,PT
Mailing Address - Street 1:144 BROWNDALE LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WIRTZ
Mailing Address - State:VA
Mailing Address - Zip Code:24184-3689
Mailing Address - Country:US
Mailing Address - Phone:630-880-3502
Mailing Address - Fax:
Practice Address - Street 1:144 BROWNDALE LN
Practice Address - Street 2:SUITE 100
Practice Address - City:WIRTZ
Practice Address - State:VA
Practice Address - Zip Code:24184-3689
Practice Address - Country:US
Practice Address - Phone:630-880-3502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206566225100000X, 2251G0304X, 2251N0400X
IL070001936225100000X, 2251G0304X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL908160Medicare UPIN