Provider Demographics
NPI:1871687350
Name:DISALVO, MARY (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DISALVO
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 LANCASTER ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22405
Mailing Address - Country:US
Mailing Address - Phone:540-373-6555
Mailing Address - Fax:
Practice Address - Street 1:600 JACKSON ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401
Practice Address - Country:US
Practice Address - Phone:540-373-3223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA229139OtherMDIPA
VA192573OtherANTHEM HEALTHKEEP PLUS