Provider Demographics
NPI:1952073934
Name:TESTA, MARY-GRACE (ATC)
Entity Type:Individual
Prefix:
First Name:MARY-GRACE
Middle Name:
Last Name:TESTA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 W GRAND AVE APT 401
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6999
Mailing Address - Country:US
Mailing Address - Phone:201-290-4460
Mailing Address - Fax:
Practice Address - Street 1:1401 BRONCO LANE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-579-0284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002642002255A2300X
IDAT-7932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer