Mary Childress
Individual provider Active NPI Physical Therapist · Draper, UT
NPI 1033580980 · NPPES record last updated Jun 20, 2024
Key facts
- NPI
- 1033580980
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Physical Therapist 225100000X
- License
- 7971 (SC)
- Practice address
- 65 E Wadsworth Park Dr Ste 230
Draper, UT 84020-8096 - Phone
- (385) 308-8034
- NPI assigned
- Oct 16, 2015
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- Yes
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PTH10588 | AL | MD | Physical Therapist |
| 37906 | FL | MD | Physical Therapist |
| 05014416A | IN | MD | Physical Therapist |
| 000025951 | MA | MD | Physical Therapist |
| 019570 | OH | MD | Physical Therapist |
| 030109 | PA | MD | Physical Therapist |
| 040-0134309 | VT | MD | Physical Therapist |
| 7971 | SC | MD | Speech-Language Pathologist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 7971 | SC | Yes |
| Physical Therapist | 225100000X | 05014416A | IN | |
| Physical Therapist | 225100000X | |||
| Physical Therapist | 225100000X | 000025951 | MA | |
| Physical Therapist | 225100000X | 37906 | FL | |
| Physical Therapist | 225100000X | PTH10588 | AL | |
| Physical Therapist | 225100000X | 048155 | NY | |
| Physical Therapist | 225100000X | 019570 | OH | |
| Physical Therapist | 225100000X | 030109 | PA | |
| Physical Therapist | 225100000X | 040-0134309 | VT |
Addresses
Primary practice location
65 E Wadsworth Park Dr Ste 230
Draper, UT 84020-8096
Mailing address
790 Remington Blvd
Bolingbrook, IL 60440-4909
Phone (630) 296-2222
Other providers in Draper, UT
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 20, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.