Provider Demographics
NPI:1679254437
Name:TITO, MARY GRACE AGUIPO
Entity Type:Individual
Prefix:PROF
First Name:MARY GRACE
Middle Name:AGUIPO
Last Name:TITO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14329 FUNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4943
Mailing Address - Country:US
Mailing Address - Phone:562-584-5962
Mailing Address - Fax:
Practice Address - Street 1:1345 AVENUE OF THE AMERICAS FL 15
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10105-0021
Practice Address - Country:US
Practice Address - Phone:212-981-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045012225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist