Provider Demographics
NPI:1174754105
Name:FAHEY, MAE GERALYN (PTA)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:GERALYN
Last Name:FAHEY
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 1:6175 GIFFORD DR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:OH
Mailing Address - Zip Code:44144-3461
Mailing Address - Country:US
Mailing Address - Phone:216-534-5596
Mailing Address - Fax:216-398-8166
Practice Address - Street 1:602 TOURNAMENT DR
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-2284
Practice Address - Country:US
Practice Address - Phone:216-534-5599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-08
Last Update Date:2009-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH00978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist