Provider Demographics
NPI:1730633561
Name:PRINCE, MARY (ATC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 31ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-1035
Mailing Address - Country:US
Mailing Address - Phone:828-291-1040
Mailing Address - Fax:
Practice Address - Street 1:141 MOBY ARENA
Practice Address - Street 2:951 W PLUM ST
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80523-0001
Practice Address - Country:US
Practice Address - Phone:970-491-6756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00013392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer