Provider Demographics
NPI:1790714475
Name:OAKLEY, MARY GRIZZLE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GRIZZLE
Last Name:OAKLEY
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 1:405 OSIGIAN BLVD
Mailing Address - Street 2:THE CANTRELL CENTER FOR PT & SPORTS MEDICINE PC
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088
Mailing Address - Country:US
Mailing Address - Phone:478-953-3535
Mailing Address - Fax:478-953-0353
Practice Address - Street 1:405 OSIGIAN BLVD
Practice Address - Street 2:THE CANTRELL CENTER FOR PT & SPORTS MEDICINE PC
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088
Practice Address - Country:US
Practice Address - Phone:478-953-3535
Practice Address - Fax:478-953-0353
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT002271225100000X, 2251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52542051OtherBCBS
GA52542051OtherBCBS