Provider Demographics
NPI:1942524665
Name:WITT, MARY A (MARY WITT, PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:WITT
Suffix:
Gender:F
Credentials:MARY WITT, PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARY MILLER, PT
Mailing Address - Street 1:PO BOX 955
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-0955
Mailing Address - Country:US
Mailing Address - Phone:970-331-5502
Mailing Address - Fax:970-328-5776
Practice Address - Street 1:247 RING NECK ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-0955
Practice Address - Country:US
Practice Address - Phone:970-331-5502
Practice Address - Fax:970-328-5776
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3954225100000X
WI3392-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist