Healthcare Provider Details

I. General information

NPI: 1194799031
Provider Name (Legal Business Name): MARY GONDECK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25320 RICHARDSON RD
FEDERALSBURG MD
21632-2403
US

IV. Provider business mailing address

803 COLLEGE LN APT. I
SALISBURY MD
21804-8669
US

V. Phone/Fax

Practice location:
  • Phone: 410-154-5575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: