Provider Demographics
NPI:1447591490
Name:MARRI, WINGSTON (PT)
Entity Type:Individual
Prefix:MR
First Name:WINGSTON
Middle Name:
Last Name:MARRI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 VILLAGE GREEN LN
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3367
Mailing Address - Country:US
Mailing Address - Phone:734-242-6282
Mailing Address - Fax:
Practice Address - Street 1:481 VILLAGE GREEN LN
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3367
Practice Address - Country:US
Practice Address - Phone:734-242-6282
Practice Address - Fax:734-242-6491
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-14
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015049225100000X, 2251G0304X, 2251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740621762Medicaid