Provider Demographics
NPI:1285653477
Name:BISSO, MARY KAY (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY KAY
Middle Name:
Last Name:BISSO
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 13550
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85216-3550
Mailing Address - Country:US
Mailing Address - Phone:480-325-3801
Mailing Address - Fax:480-325-3805
Practice Address - Street 1:3048 E BASELINE RD STE 125
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-7288
Practice Address - Country:US
Practice Address - Phone:602-313-4664
Practice Address - Fax:480-222-1457
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0827225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
73147Medicare ID - Type Unspecified