Provider Demographics
NPI:1770839052
Name:DAUBERT, MARY ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:DAUBERT
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 1:5615 US HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-2002
Mailing Address - Country:US
Mailing Address - Phone:609-845-7201
Mailing Address - Fax:
Practice Address - Street 1:5615 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-2002
Practice Address - Country:US
Practice Address - Phone:609-845-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.003001225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant