Healthcare Provider Details

I. General information

NPI: 1821115783
Provider Name (Legal Business Name): MARY KAY EASTMAN P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 RICHLAND AVE SUITE 108
ATHENS OH
45701-3700
US

IV. Provider business mailing address

6379 GURA RD
ATHENS OH
45701-9615
US

V. Phone/Fax

Practice location:
  • Phone: 140-593-8001
  • Fax: 740-593-5968
Mailing address:
  • Phone: 740-593-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT-002517
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: