Provider Demographics
NPI:1629364831
Name:DEADERICK, MARY O'BRYAN (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:O'BRYAN
Last Name:DEADERICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:OBRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2307 S DALE MABRY HWY
Mailing Address - Street 2:STE F
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-6322
Mailing Address - Country:US
Mailing Address - Phone:813-374-9508
Mailing Address - Fax:813-443-5599
Practice Address - Street 1:2307 S DALE MABRY HWY
Practice Address - Street 2:STE F
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-6322
Practice Address - Country:US
Practice Address - Phone:813-374-9508
Practice Address - Fax:813-443-5599
Is Sole Proprietor?:No
Enumeration Date:2011-06-27
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8938225100000X
FL31081225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist