Provider Demographics
NPI:1194813261
Name:MERRY, MARY ELLEN (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MERRY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:KOENIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1901 N MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-6824
Mailing Address - Country:US
Mailing Address - Phone:910-814-1555
Mailing Address - Fax:910-814-1556
Practice Address - Street 1:1901 N MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-6824
Practice Address - Country:US
Practice Address - Phone:910-814-1555
Practice Address - Fax:910-814-1556
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10645225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist