Provider Demographics
NPI:1366767626
Name:BRINA, MARY GRACE (RPT)
Entity type:Individual
Prefix:MISS
First Name:MARY GRACE
Middle Name:
Last Name:BRINA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8749 N ELMORE ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-1943
Mailing Address - Country:US
Mailing Address - Phone:561-523-6628
Mailing Address - Fax:
Practice Address - Street 1:8749 N ELMORE ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-1943
Practice Address - Country:US
Practice Address - Phone:561-523-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017499225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist