Healthcare Provider Details

I. General information

NPI: 1629021464
Provider Name (Legal Business Name): MARYANNE DEPUTRON MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1651-53 PULASKI HIGHWAY
BEAR DE
19701-1453
US

IV. Provider business mailing address

1265 WAYNE AVENUE, SUITE 308 119 PROFESSIONAL BUILDING
INDIANA PA
15701-3508
US

V. Phone/Fax

Practice location:
  • Phone: 302-834-1550
  • Fax: 302-834-1549
Mailing address:
  • Phone: 724-801-8095
  • Fax: 724-801-8147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ1-0001053
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT009263L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: