Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | PT30861 | FL |
NPI | 1083079552 |
---|---|
Provider Name | Mabelle Tercero Mcphilomy |
First Address | Orange Park, FL 32065-5615 |
Second Address | Orange Park, FL 32065-5615 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2015 |
Last Update Date | 29/12/2015 |