Provider Demographics
NPI:1659809366
Name:PARKER, MARY RAINEY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RAINEY
Last Name:PARKER
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 1:236 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2636
Mailing Address - Country:US
Mailing Address - Phone:912-242-3402
Mailing Address - Fax:
Practice Address - Street 1:236 FLORIDA ST
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2636
Practice Address - Country:US
Practice Address - Phone:912-242-3402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000687629EMedicaid