Provider Demographics
NPI:1447437694
Name:MASTNY, MARY J (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:MASTNY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 CLARENCE AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-2776
Mailing Address - Country:US
Mailing Address - Phone:708-795-5770
Mailing Address - Fax:
Practice Address - Street 1:6801 HIGH GROVE BLVD
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7585
Practice Address - Country:US
Practice Address - Phone:630-734-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant