Provider Demographics
NPI:1255560611
Name:BASSOUS, MARY MAUREEN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MAUREEN
Last Name:BASSOUS
Suffix:
Gender:F
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:PO BOX 2898
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-2898
Mailing Address - Country:US
Mailing Address - Phone:928-567-6683
Mailing Address - Fax:928-567-2477
Practice Address - Street 1:15 E HWY 260
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-2898
Practice Address - Country:US
Practice Address - Phone:928-567-6683
Practice Address - Fax:928-567-2477
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist