1487053534 NPI number — MARA ELIZABETH MUEHLENKAMP DPT

Table of content: MARA ELIZABETH MUEHLENKAMP DPT (NPI 1487053534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487053534 NPI number — MARA ELIZABETH MUEHLENKAMP DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUEHLENKAMP
Provider First Name:
MARA
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUEHLENKAMP
Provider Other First Name:
MARA
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1487053534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3455 HIGHWAY 81 SOUTH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOGANVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30052-3918
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-554-0665
Provider Business Mailing Address Fax Number:
770-554-0685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
998 HOSPITALITY WAY
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-273-9776
Provider Business Practice Location Address Fax Number:
410-273-9777
Provider Enumeration Date:
08/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT25161 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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