Provider Demographics
NPI:1659636827
Name:POLVOORDE-DIVIS, MARY BETH (MS, MPT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:MARY BETH
Middle Name:
Last Name:POLVOORDE-DIVIS
Suffix:
Gender:F
Credentials:MS, MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1733
Mailing Address - Country:US
Mailing Address - Phone:610-891-0975
Mailing Address - Fax:
Practice Address - Street 1:719 S CHESTER RD
Practice Address - Street 2:
Practice Address - City:SWARTHMORE
Practice Address - State:PA
Practice Address - Zip Code:19081-2710
Practice Address - Country:US
Practice Address - Phone:610-543-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008160L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist