Provider Demographics
NPI:1336301464
Name:SPROUSE, MARY JO (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:
Last Name:SPROUSE
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 1:114 IVEY RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5347
Mailing Address - Country:US
Mailing Address - Phone:270-527-9801
Mailing Address - Fax:
Practice Address - Street 1:10456 US HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029-9020
Practice Address - Country:US
Practice Address - Phone:270-898-6240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT - 0008492251G0304X
IN05009431A2251G0304X
PAPT001024E2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics