Provider Demographics
NPI:1063767556
Name:PERSON, MARYAM (ITFS)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:PERSON
Suffix:
Gender:F
Credentials:ITFS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6211 PITCHKETTLE RD
Mailing Address - Street 2:APT 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4068
Mailing Address - Country:US
Mailing Address - Phone:919-896-0279
Mailing Address - Fax:
Practice Address - Street 1:6211 PITCHKETTLE RD
Practice Address - Street 2:APT 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-4068
Practice Address - Country:US
Practice Address - Phone:919-896-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist