Provider Demographics
NPI:1619012648
Name:TAN, MARY GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:TAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13284 WENTWORTH ST
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-5822
Mailing Address - Country:US
Mailing Address - Phone:818-994-9266
Mailing Address - Fax:626-576-5890
Practice Address - Street 1:55 S RAYMOND AVE
Practice Address - Street 2:STE 100
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-7100
Practice Address - Country:US
Practice Address - Phone:626-576-0591
Practice Address - Fax:626-576-5890
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 33405225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 33405OtherPHYSICAL THERAPY LICENSE