Provider Demographics
NPI:1588035596
Name:LARRY, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LARRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1807 FULTON DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-3939
Mailing Address - Country:US
Mailing Address - Phone:772-828-5148
Mailing Address - Fax:772-429-0733
Practice Address - Street 1:1807 FULTON DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-3939
Practice Address - Country:US
Practice Address - Phone:772-828-5148
Practice Address - Fax:772-429-0733
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator