Provider Demographics
NPI:1396894176
Name:BANG, MARILOU IRENE (PT)
Entity type:Individual
Prefix:MRS
First Name:MARILOU
Middle Name:IRENE
Last Name:BANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MARILOU
Other - Middle Name:IRENE
Other - Last Name:BANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2335 CHAD CT
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-5535
Mailing Address - Country:US
Mailing Address - Phone:707-254-7612
Mailing Address - Fax:
Practice Address - Street 1:1515 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2915
Practice Address - Country:US
Practice Address - Phone:707-258-4912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT14907225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist