Provider Demographics
NPI:1225390768
Name:ROUSE, MARY A
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:ROUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2106
Mailing Address - Country:US
Mailing Address - Phone:607-798-7117
Mailing Address - Fax:607-798-0074
Practice Address - Street 1:18 BROAD ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2106
Practice Address - Country:US
Practice Address - Phone:607-798-7117
Practice Address - Fax:607-798-0074
Is Sole Proprietor?:No
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist