Provider Demographics
NPI:1609937978
Name:POWELL-PENRITH, MARY M (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:POWELL-PENRITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:7514 GIRARD AVE
Mailing Address - Street 2:SUITE 1-513
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5149
Mailing Address - Country:US
Mailing Address - Phone:858-736-6672
Mailing Address - Fax:858-565-6911
Practice Address - Street 1:8344 CLAIREMONT MESA BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1307
Practice Address - Country:US
Practice Address - Phone:858-736-6672
Practice Address - Fax:858-565-6911
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11967225000000X, 225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic