Provider Demographics
NPI:1649511684
Name:MAYBERRY, MARY M (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 NORTHWEST ELDREDGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:ORTING
Mailing Address - State:WA
Mailing Address - Zip Code:98360-0486
Mailing Address - Country:US
Mailing Address - Phone:253-341-1276
Mailing Address - Fax:
Practice Address - Street 1:6004 WESTGATE BLVD
Practice Address - Street 2:#220
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2503
Practice Address - Country:US
Practice Address - Phone:253-759-4065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60045694225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant