Provider Demographics
NPI:1598304032
Name:GAETOS, MARY ANN (PTA)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:GAETOS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2706 STARFALL DR
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1444
Mailing Address - Country:US
Mailing Address - Phone:323-684-7285
Mailing Address - Fax:
Practice Address - Street 1:2706 STARFALL DR
Practice Address - Street 2:
Practice Address - City:LA CRESCENTA
Practice Address - State:CA
Practice Address - Zip Code:91214-1444
Practice Address - Country:US
Practice Address - Phone:323-684-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-01
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA9523225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant