Healthcare Provider Details

I. General information

NPI: 1942607163
Provider Name (Legal Business Name): MARY SPINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MACARTHUR BLVD
MUNSTER IN
46321-2915
US

IV. Provider business mailing address

801 MACARTHUR BLVD
MUNSTER IN
46321-2915
US

V. Phone/Fax

Practice location:
  • Phone: 219-378-0464
  • Fax:
Mailing address:
  • Phone: 219-378-0464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000527A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: