Healthcare Provider Details

I. General information

NPI: 1174592935
Provider Name (Legal Business Name): MARY L NASTAN RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11808 MARSH HEAD RD
SARASOTA FL
34240-8883
US

IV. Provider business mailing address

11808 MARSH HEAD RD
SARASOTA FL
34240-8883
US

V. Phone/Fax

Practice location:
  • Phone: 941-378-5249
  • Fax:
Mailing address:
  • Phone: 941-378-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2278
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2278
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: