Provider Demographics
NPI:1629089693
Name:ROTH, MARY C (MSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:ROTH
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:2835 DUBLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1662
Mailing Address - Country:US
Mailing Address - Phone:719-533-1318
Mailing Address - Fax:
Practice Address - Street 1:3221 N WINDSONG DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1222
Practice Address - Country:US
Practice Address - Phone:928-910-7010
Practice Address - Fax:928-910-7011
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
102255329OtherOWCP
102255329OtherOWCP