Provider Demographics
NPI:1487080842
Name:LAGARE, MARY GRACE (PTR)
Entity type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:LAGARE
Suffix:
Gender:F
Credentials:PTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 163
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-0163
Mailing Address - Country:US
Mailing Address - Phone:619-838-1728
Mailing Address - Fax:
Practice Address - Street 1:4554 W 48TH ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-8721
Practice Address - Country:US
Practice Address - Phone:619-838-1728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist