Provider Demographics
NPI:1639339245
Name:BOULOS, MARY (DPT)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 SANDERS PL
Mailing Address - Street 2:
Mailing Address - City:POMPTON PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07444-1236
Mailing Address - Country:US
Mailing Address - Phone:973-296-5769
Mailing Address - Fax:
Practice Address - Street 1:18 SANDERS PL
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1236
Practice Address - Country:US
Practice Address - Phone:973-296-5769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00481400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist