Provider Demographics
NPI:1629298377
Name:O'CONNOR, MARY LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:10765 CREBS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2764
Mailing Address - Country:US
Mailing Address - Phone:818-366-2588
Mailing Address - Fax:818-366-2588
Practice Address - Street 1:10605 BALBOA BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6342
Practice Address - Country:US
Practice Address - Phone:818-832-7200
Practice Address - Fax:818-832-7249
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist