Provider Demographics
NPI:1588743033
Name:JOSEPH, MARY ELLEN (PTA)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 E CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3568
Mailing Address - Country:US
Mailing Address - Phone:480-290-2974
Mailing Address - Fax:
Practice Address - Street 1:2423 W DUNLAP AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2830
Practice Address - Country:US
Practice Address - Phone:602-870-1414
Practice Address - Fax:602-870-4141
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7174A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7174AOtherLICENSE