Provider Demographics
NPI:1780817148
Name:MATTIS, MARY (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:MATTIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:LIBBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:465 GREENWICH DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-6541
Mailing Address - Country:US
Mailing Address - Phone:386-846-7062
Mailing Address - Fax:
Practice Address - Street 1:943 PINE LOG RD
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29803-7330
Practice Address - Country:US
Practice Address - Phone:803-649-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-01
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT14465225100000X
SC10091225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist