Provider Demographics
NPI:1255734083
Name:POBLETE, MARY (PT, DPT, C/NDT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:POBLETE
Suffix:
Gender:F
Credentials:PT, DPT, C/NDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BEACON ST
Mailing Address - Street 2:APARTMENT 2
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 MILITIA DR
Practice Address - Street 2:SUITE 17
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-4737
Practice Address - Country:US
Practice Address - Phone:949-395-7191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187352251P0200X
CA331902251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics