Provider Demographics
NPI:1033260435
Name:EMERSON, MARY ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:EMERSON
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:E5930 IRISH VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:PLAIN
Mailing Address - State:WI
Mailing Address - Zip Code:53577-9727
Mailing Address - Country:US
Mailing Address - Phone:608-963-8493
Mailing Address - Fax:
Practice Address - Street 1:1050 DIVISION ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1931
Practice Address - Country:US
Practice Address - Phone:608-847-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10380-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36124300Medicaid