Provider Demographics
NPI:1144857699
Name:VEGA, MARY C (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:VEGA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:WEBSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 510326
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33951-0326
Mailing Address - Country:US
Mailing Address - Phone:941-888-4561
Mailing Address - Fax:941-347-4695
Practice Address - Street 1:2200 KINGS HWY UNIT 2F
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-5760
Practice Address - Country:US
Practice Address - Phone:941-888-4561
Practice Address - Fax:941-347-4695
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT5676225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist