Provider Demographics
NPI:1104130798
Name:TOWER-MATTESON, MARY DELIA (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DELIA
Last Name:TOWER-MATTESON
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 1:115 WILLIAMS ROAD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:12837-2415
Mailing Address - Country:US
Mailing Address - Phone:518-642-1660
Mailing Address - Fax:
Practice Address - Street 1:115 WILLIAMS ROAD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:12837-2415
Practice Address - Country:US
Practice Address - Phone:518-642-1660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT040-0003389225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist