Provider Demographics
NPI:1710477849
Name:LAFAR, MARY ROBERTSON (PTA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ROBERTSON
Last Name:LAFAR
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1531
Mailing Address - Country:US
Mailing Address - Phone:336-988-5305
Mailing Address - Fax:
Practice Address - Street 1:117 E KINGS HWY
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-5201
Practice Address - Country:US
Practice Address - Phone:336-623-9711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6503225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant