Provider Demographics
NPI:1538938154
Name:GROW, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 TAOS ST
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-2637
Mailing Address - Country:US
Mailing Address - Phone:575-518-9039
Mailing Address - Fax:
Practice Address - Street 1:2610 TRINITY DR STE 16
Practice Address - Street 2:
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-2374
Practice Address - Country:US
Practice Address - Phone:505-551-0523
Practice Address - Fax:505-570-4640
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1372225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant