Provider Demographics
NPI:1457472953
Name:PEABODY, MARY DENISE (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DENISE
Last Name:PEABODY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:DENISE
Other - Last Name:SCRUGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 BERKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7366
Mailing Address - Country:US
Mailing Address - Phone:405-330-6468
Mailing Address - Fax:
Practice Address - Street 1:6525 N MERIDIAN AVE STE 311
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1410
Practice Address - Country:US
Practice Address - Phone:405-721-1115
Practice Address - Fax:405-721-2025
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK836225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist