Provider Demographics
NPI:1487950077
Name:HADDOCK, MARY ELLEN (CFTS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:HADDOCK
Suffix:
Gender:F
Credentials:CFTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:AYDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28513-7252
Mailing Address - Country:US
Mailing Address - Phone:252-746-3492
Mailing Address - Fax:252-746-4838
Practice Address - Street 1:131 THIRD STREET
Practice Address - Street 2:
Practice Address - City:AYDEN
Practice Address - State:NC
Practice Address - Zip Code:28513-7252
Practice Address - Country:US
Practice Address - Phone:252-746-3492
Practice Address - Fax:252-746-4838
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFTS1166225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter