Provider Demographics
NPI:1174725295
Name:EGBERT, MARY E (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:EGBERT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1535 COGSWELL ST STE C19
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2740
Mailing Address - Country:US
Mailing Address - Phone:801-440-0214
Mailing Address - Fax:
Practice Address - Street 1:1535 COGSWELL ST STE C19
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2740
Practice Address - Country:US
Practice Address - Phone:801-440-0214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52772562401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist