Provider Demographics
NPI:1942607163
Name:SPINA, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SPINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2915
Mailing Address - Country:US
Mailing Address - Phone:219-378-0464
Mailing Address - Fax:
Practice Address - Street 1:801 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2915
Practice Address - Country:US
Practice Address - Phone:219-378-0464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000527A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer