Provider Demographics
NPI:1386776144
Name:GUEVARRA, MARY GRACE (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:GUEVARRA
Suffix:
Gender:F
Credentials:PT
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Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2211 W MAGNOLIA BLVD STE 160
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1757
Practice Address - Country:US
Practice Address - Phone:818-876-4195
Practice Address - Fax:818-729-0410
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA32582208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32582OtherCA LICENSE