Provider Demographics
NPI:1104150341
Name:CARBONELL, MARY ELAINE GINES (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY ELAINE
Middle Name:GINES
Last Name:CARBONELL
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 1:848 PEIRSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-9762
Mailing Address - Country:US
Mailing Address - Phone:315-331-2086
Mailing Address - Fax:
Practice Address - Street 1:848 PEIRSON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-9762
Practice Address - Country:US
Practice Address - Phone:315-879-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030046225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist