Provider Demographics
NPI:1619021896
Name:SMITH, MARY MARGARET (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:SMITH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:STRIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2910 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:602-406-3008
Mailing Address - Fax:602-406-6108
Practice Address - Street 1:4530 E MUIRWOOD DR STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048
Practice Address - Country:US
Practice Address - Phone:480-759-5808
Practice Address - Fax:480-759-0647
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPT-007137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ068163OtherAHCCCS ID NO