Provider Demographics
NPI:1477820645
Name:SISON, MARY JANE TAGABI (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY JANE
Middle Name:TAGABI
Last Name:SISON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 BAYBERRY CT
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29170-2400
Mailing Address - Country:US
Mailing Address - Phone:803-957-0666
Mailing Address - Fax:
Practice Address - Street 1:1895 SAINT MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2403
Practice Address - Country:US
Practice Address - Phone:803-395-2600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2855225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist