Provider Demographics
NPI:1235111246
Name:REGEDANZ, ROSALIE M (PT)
Entity Type:Individual
Prefix:MS
First Name:ROSALIE
Middle Name:M
Last Name:REGEDANZ
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46546-0308
Mailing Address - Country:US
Mailing Address - Phone:574-273-6546
Mailing Address - Fax:574-273-5295
Practice Address - Street 1:900 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1634
Practice Address - Country:US
Practice Address - Phone:574-936-9600
Practice Address - Fax:574-936-9612
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001121A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200332623OtherTAX ID
IN216260AMedicare ID - Type Unspecified