Provider Demographics
NPI:1376863324
Name:STRICKLAND, MARY ROSE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY ROSE
Middle Name:
Last Name:STRICKLAND
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARY ROSE
Other - Middle Name:
Other - Last Name:LUCIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2639 NEW PINERY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1110
Mailing Address - Country:US
Mailing Address - Phone:608-742-9356
Mailing Address - Fax:608-742-9358
Practice Address - Street 1:2639 NEW PINERY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1110
Practice Address - Country:US
Practice Address - Phone:608-742-9356
Practice Address - Fax:608-742-9358
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11464-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist