Provider Demographics
NPI:1356614242
Name:VERISSIMO, MARY ALEXANDRA (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALEXANDRA
Last Name:VERISSIMO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1504 FAITH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-6874
Mailing Address - Country:US
Mailing Address - Phone:309-369-6593
Mailing Address - Fax:
Practice Address - Street 1:3510 PARK AVENUE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7361
Practice Address - Country:US
Practice Address - Phone:843-607-4493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018923225100000X, 2251P0200X
SC8301225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist