Provider Demographics
NPI:1861004145
Name:ESPIRITU, MARY GRACE (PT)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:ESPIRITU
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 1:67 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1530
Mailing Address - Country:US
Mailing Address - Phone:917-326-1960
Mailing Address - Fax:
Practice Address - Street 1:67 GORDON AVE
Practice Address - Street 2:
Practice Address - City:TENAFLY
Practice Address - State:NJ
Practice Address - Zip Code:07670-1530
Practice Address - Country:US
Practice Address - Phone:917-326-1960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA00794700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist