Provider Demographics
NPI:1730485681
Name:IMBODEN, MARY MARGARET
Entity Type:Individual
Prefix:MR
First Name:MARY
Middle Name:MARGARET
Last Name:IMBODEN
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 1:31825 BAYVIEW DR
Mailing Address - Street 2:TOWNHOME # 112
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2485
Mailing Address - Country:US
Mailing Address - Phone:440-476-6766
Mailing Address - Fax:
Practice Address - Street 1:31825 BAYVIEW DR
Practice Address - Street 2:TOWNHOME # 112
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2485
Practice Address - Country:US
Practice Address - Phone:440-476-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH06377225200000X
VA2306602313225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant