Provider Demographics
NPI:1629353966
Name:ALFONSO, MARIANNE GRACE TADIQUE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE GRACE
Middle Name:TADIQUE
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W RUTHERFORD DR
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2026
Mailing Address - Country:US
Mailing Address - Phone:302-588-6877
Mailing Address - Fax:
Practice Address - Street 1:505 GREENBANK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-3164
Practice Address - Country:US
Practice Address - Phone:302-998-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002698225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist