Provider Demographics
NPI:1003883208
Name:DELACY, MARY KATHLEEN (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
Last Name:DELACY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1710
Mailing Address - Country:US
Mailing Address - Phone:612-439-4222
Mailing Address - Fax:651-730-1979
Practice Address - Street 1:6025 LAKE RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1712
Practice Address - Country:US
Practice Address - Phone:612-439-4222
Practice Address - Fax:651-730-1979
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist