Provider Demographics
NPI:1740250620
Name:MAST, VIVIAN (PT)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:
Last Name:MAST
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3528 WADE AVENUE
Mailing Address - Street 2:#139
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4048
Mailing Address - Country:US
Mailing Address - Phone:919-782-5954
Mailing Address - Fax:919-859-9444
Practice Address - Street 1:2418 BLUE RIDGE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6480
Practice Address - Country:US
Practice Address - Phone:919-782-5954
Practice Address - Fax:919-859-9444
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8793225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD9492OtherMEDCOST
NC5947795OtherAETNA
NC130GCOtherBLUE CROSS BLUE SHIELD
NC130GCOtherBLUE CROSS BLUE SHIELD