Provider Demographics
NPI:1952555823
Name:CAMACHO, MARY GRAYLE JALALAIN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY GRAYLE
Middle Name:JALALAIN
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
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Mailing Address - Street 1:28022 MARGUERITE PKWY
Mailing Address - Street 2:APT. C
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-3611
Mailing Address - Country:US
Mailing Address - Phone:714-423-1315
Mailing Address - Fax:
Practice Address - Street 1:22 ODYSSEY
Practice Address - Street 2:#165
Practice Address - City:IRVINE,
Practice Address - State:CA
Practice Address - Zip Code:92618
Practice Address - Country:US
Practice Address - Phone:949-727-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016394225100000X
CA37616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist