Healthcare Provider Details

I. General information

NPI: 1760447536
Provider Name (Legal Business Name): MARY LYDIA ENGLES PT, MS, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 W POINT LOMA BLVD
SAN DIEGO CA
92110-5605
US

IV. Provider business mailing address

4120 W POINT LOMA BLVD
SAN DIEGO CA
92110-5605
US

V. Phone/Fax

Practice location:
  • Phone: 619-226-4131
  • Fax: 619-226-4124
Mailing address:
  • Phone: 619-226-4131
  • Fax: 619-226-4124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6252
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT6252
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT6252
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: