Provider Demographics
NPI:1215091707
Name:CAMILLERI, MARY CAROLE (PT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:CAROLE
Last Name:CAMILLERI
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 1:2333 BIDDLE AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48192-4668
Mailing Address - Country:US
Mailing Address - Phone:734-308-9179
Mailing Address - Fax:
Practice Address - Street 1:2333 BIDDLE ST
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-4668
Practice Address - Country:US
Practice Address - Phone:734-246-9498
Practice Address - Fax:734-246-6071
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012124225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist