Provider Demographics
NPI:1013917087
Name:HOLBROOK, MARY BETH (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:HOLBROOK
Suffix:
Gender:
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 SHAMROCK DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9178
Mailing Address - Country:US
Mailing Address - Phone:812-629-5857
Mailing Address - Fax:
Practice Address - Street 1:1328 N WEINBACH AVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-4307
Practice Address - Country:US
Practice Address - Phone:812-550-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2025-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004613A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8700183000Medicaid
KYK005560OtherTRICARE
KYPOO332298OtherRR MEDICARE
TN0446631Medicare PIN
KYPOO332298OtherRR MEDICARE