Provider Demographics
NPI:1306164470
Name:SY, MARY JANE BERONGAN (PT)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:BERONGAN
Last Name:SY
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 1:104 LEGACY LN
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-8754
Mailing Address - Country:US
Mailing Address - Phone:501-701-8617
Mailing Address - Fax:501-762-0399
Practice Address - Street 1:3655B MALVERN RD
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-6716
Practice Address - Country:US
Practice Address - Phone:501-701-8617
Practice Address - Fax:501-762-0399
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12610225100000X
AR3248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist