MEDICARE: MARY ALEXANDRA VERISSIMO DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	8301	SC

General Provider Information

NPI Number	:	1356614242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY ALEXANDRA VERISSIMO DPT

Provider Business Mailing Address
First Line	:	1504 FAITH ST
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-6874
Country	:	US
Telephone Number	:	309-369-6593
Fax Number	:

Provider Business Practice Location Address
First Line	:	3510 PARK AVENUE BLVD STE 105
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29466-7361
Country	:	US
Telephone Number	:	843-607-4493
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2012
Last Update Date	:	06/20/2026

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