Provider Demographics
NPI:1366837064
Name:WISEMAN, MARY (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:CALLENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:805 BROOKFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:805 BROOKFIELD CIR
Practice Address - Street 2:
Practice Address - City:MACUNGIE
Practice Address - State:PA
Practice Address - Zip Code:18062-1158
Practice Address - Country:US
Practice Address - Phone:609-364-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-31
Last Update Date:2018-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01551800225100000X
PAPT023632225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist