Provider Demographics
NPI:1760447536
Name:ENGLES, MARY LYDIA (PT, MS, OCS)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:LYDIA
Last Name:ENGLES
Suffix:
Gender:F
Credentials:PT, MS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 W POINT LOMA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5605
Mailing Address - Country:US
Mailing Address - Phone:619-226-4131
Mailing Address - Fax:619-226-4124
Practice Address - Street 1:4120 W POINT LOMA BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5605
Practice Address - Country:US
Practice Address - Phone:619-226-4131
Practice Address - Fax:619-226-4124
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT6252225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PT6252Medicaid
CA070112OtherHEALTH NET PIN NUMBER
CA00PT62520OtherBLUE CROSS PIN NUMBER
CA070112OtherHEALTH NET PIN NUMBER