Provider Demographics
NPI:1356790380
Name:CEBUL, MARK (PT, DPT, CSCS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:CEBUL
Suffix:
Gender:M
Credentials:PT, DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 CORPORATE PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6959
Mailing Address - Country:US
Mailing Address - Phone:704-360-2796
Mailing Address - Fax:704-360-2798
Practice Address - Street 1:10810 MALLARD CREEK ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-6959
Practice Address - Country:US
Practice Address - Phone:704-510-8000
Practice Address - Fax:704-510-8006
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC163582251X0800X
NCP16358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic