Provider Demographics
NPI:1700120037
Name:MAK, ASHLEY J (PT,DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:J
Last Name:MAK
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MARSH RD
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-2541
Mailing Address - Country:US
Mailing Address - Phone:646-821-3390
Mailing Address - Fax:
Practice Address - Street 1:24 MARSH RD
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-2541
Practice Address - Country:US
Practice Address - Phone:646-821-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297766225100000X
NJ40QA01474900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist