Provider Demographics
NPI:1104960343
Name:PHILLIPS, MARIETTA JOANNE (PT)
Entity type:Individual
Prefix:MRS
First Name:MARIETTA
Middle Name:JOANNE
Last Name:PHILLIPS
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 1:45 TELLIDORA TRL
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-9404
Mailing Address - Country:US
Mailing Address - Phone:585-293-1285
Mailing Address - Fax:
Practice Address - Street 1:2755 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-1304
Practice Address - Country:US
Practice Address - Phone:585-290-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NY012008-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB4077Medicare PIN