Provider Demographics
NPI:1861546723
Name:CARPENTER, MARY LOU (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LOU
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1416 S WEYMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3945
Mailing Address - Country:US
Mailing Address - Phone:310-832-8817
Mailing Address - Fax:
Practice Address - Street 1:23441 MADISON ST
Practice Address - Street 2:SUITE 330, BUILDING 8
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4725
Practice Address - Country:US
Practice Address - Phone:310-665-7141
Practice Address - Fax:310-665-7119
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT12959225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist