Provider Demographics
NPI:1851327258
Name:SEMBRANO, MARY GRACE FONDEVILLA (PT)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:FONDEVILLA
Last Name:SEMBRANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY GRACE
Other - Middle Name:CAPUNO
Other - Last Name:FONDEVILLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16 TULIP COURT
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731
Mailing Address - Country:US
Mailing Address - Phone:843-276-6709
Mailing Address - Fax:732-202-8773
Practice Address - Street 1:527 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:732-905-0700
Practice Address - Fax:732-364-4566
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA010211002251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
080108BMPMedicare ID - Type Unspecified