MEDICARE: MS. MARY R. DAULONG P.T.

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	1008928	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0019105	OTHER	TX	BCBS BLUE LINK
2	8T0825	OTHER	TX	BCBS PAR PLAN PROVIDER #

General Provider Information

NPI Number	:	1699778845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY R. DAULONG P.T.

Provider Business Mailing Address
First Line	:	15814 CHAMPION FOREST DR
Second Line	:	SUITE 240
City	:	SPRING
State	:	TX
Zip	:	77379-7141
Country	:	US
Telephone Number	:	281-866-9505
Fax Number	:	281-587-9791

Provider Business Practice Location Address
First Line	:	15814 CHAMPION FOREST DR
Second Line	:	STE 240
City	:	SPRING
State	:	TX
Zip	:	77379-7141
Country	:	US
Telephone Number	:	281-866-9505
Fax Number	:	281-587-9791

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	12/29/2008

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