Provider Demographics
NPI:1750592929
Name:PERILLO, MARIAN FORD (PT)
Entity type:Individual
Prefix:MRS
First Name:MARIAN
Middle Name:FORD
Last Name:PERILLO
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 1:6607 MIMOSA ST
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9579
Mailing Address - Country:US
Mailing Address - Phone:704-607-9989
Mailing Address - Fax:704-684-4284
Practice Address - Street 1:6607 MIMOSA ST
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079
Practice Address - Country:US
Practice Address - Phone:704-607-9989
Practice Address - Fax:704-684-4284
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2018-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17502251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics