Provider Demographics
NPI:1194157115
Name:EZZEDDINE, MARY (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:EZZEDDINE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BROZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:7310 RITCHIE HWY
Mailing Address - Street 2:STE 500
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061
Mailing Address - Country:US
Mailing Address - Phone:410-766-4047
Mailing Address - Fax:410-766-4049
Practice Address - Street 1:4251 LEGION RD STE 107
Practice Address - Street 2:
Practice Address - City:HOPE MILLS
Practice Address - State:NC
Practice Address - Zip Code:28348-6200
Practice Address - Country:US
Practice Address - Phone:910-429-0600
Practice Address - Fax:910-429-0602
Is Sole Proprietor?:No
Enumeration Date:2013-08-01
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14353225100000X
VA2305209477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist