Provider Demographics
NPI:1669686077
Name:TRUESDALE, MARISKA CHARLENE (PT, CFM)
Entity type:Individual
Prefix:
First Name:MARISKA
Middle Name:CHARLENE
Last Name:TRUESDALE
Suffix:
Gender:F
Credentials:PT, CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 PINE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-2596
Mailing Address - Country:US
Mailing Address - Phone:910-619-4803
Mailing Address - Fax:910-395-5773
Practice Address - Street 1:3909 OLEANDER DR
Practice Address - Street 2:SUITE D
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6730
Practice Address - Country:US
Practice Address - Phone:910-619-4803
Practice Address - Fax:910-395-5773
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224900000X, 225000000X
NC4979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter