Provider Demographics
NPI:1669057527
Name:SERGHIOU, MARY JANE (OT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:SERGHIOU
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77555-5302
Mailing Address - Country:US
Mailing Address - Phone:409-772-2222
Mailing Address - Fax:
Practice Address - Street 1:PEDIATRIC PRIMARY CARE AT BAY COLONY
Practice Address - Street 2:2785 GULF FREEWAY SOUTH SUITE 2.200
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573
Practice Address - Country:US
Practice Address - Phone:888-886-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102469225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102469OtherOT LICENSE