Provider Demographics
NPI:1821115783
Name:EASTMAN, MARY KAY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6379 GURA RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-9615
Mailing Address - Country:US
Mailing Address - Phone:740-593-3945
Mailing Address - Fax:
Practice Address - Street 1:507 RICHLAND AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-3700
Practice Address - Country:US
Practice Address - Phone:140-593-8001
Practice Address - Fax:740-593-5968
Is Sole Proprietor?:No
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT-0025172251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics