Provider Demographics
NPI:1528066198
Name:WHITE, MARY (PT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:WHITE
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 1:27118 MOUNTAIN PARK RD
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439
Mailing Address - Country:US
Mailing Address - Phone:303-325-5329
Mailing Address - Fax:303-670-3323
Practice Address - Street 1:3045 WHITMAN DR.
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-2364
Practice Address - Country:US
Practice Address - Phone:303-325-5329
Practice Address - Fax:303-670-3323
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7572225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO7572OtherPHYSICAL THERAPY LICENSE
CO7572OtherPHYSICAL THERAPY LICENSE