Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225000000X | Orthotic Fitter | PT 11967 | CA |
Y | 225100000X | Physical Therapist | PT 11967 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | PT 11967 | CA |
NPI | 1609937978 |
---|---|
Provider Name | Mrs. Mary M Powell-Penrith |
First Address | La Jolla, CA 92037-5149 |
Second Address | San Diego, CA 92111-1307 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/12/2006 |
Last Update Date | 16/09/2016 |