Provider Demographics
NPI:1841217304
Name:GOLOB, MARY (PT DPT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:GOLOB
Suffix:
Gender:F
Credentials:PT DPT
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:GOLOB
Other - Last Name:FUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:1431 FUTCH CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9373
Mailing Address - Country:US
Mailing Address - Phone:910-686-2613
Mailing Address - Fax:
Practice Address - Street 1:8044 MARKET ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9384
Practice Address - Country:US
Practice Address - Phone:910-686-6440
Practice Address - Fax:910-686-6441
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
079WHOtherBCBS
079WHOtherBCBS