Healthcare Provider Details

I. General information

NPI: 1477072619
Provider Name (Legal Business Name): MARY CLARK CASTRO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY CLARK STRANGE PT

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 03/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST STE 210
JACKSON MS
39202-2000
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 103
MEMPHIS TN
38120-9446
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-3202
  • Fax: 601-714-3416
Mailing address:
  • Phone: 901-227-3255
  • Fax: 901-227-3205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6258
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: