Provider Demographics
NPI:1124311261
Name:SUAREZ, MARY JANE VISDA (LPT)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:VISDA
Last Name:SUAREZ
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3040
Mailing Address - Country:US
Mailing Address - Phone:336-416-1813
Mailing Address - Fax:
Practice Address - Street 1:3230 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3040
Practice Address - Country:US
Practice Address - Phone:336-416-1813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10192225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist