Provider Demographics
NPI:1730305244
Name:OLIVE, MARYKAY (PT)
Entity Type:Individual
Prefix:
First Name:MARYKAY
Middle Name:
Last Name:OLIVE
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 1:42882 NASHUA ST
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-3632
Mailing Address - Country:US
Mailing Address - Phone:703-729-2782
Mailing Address - Fax:
Practice Address - Street 1:700 TOLL HOUSE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4575
Practice Address - Country:US
Practice Address - Phone:301-815-8878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21539225100000X
VA2305204655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist