Provider Demographics
NPI:1568521920
Name:DEANE, MARJORIE WILSON (PT)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:WILSON
Last Name:DEANE
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 1:824 W NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-1828
Mailing Address - Country:US
Mailing Address - Phone:937-778-8691
Mailing Address - Fax:
Practice Address - Street 1:601 W HIGH ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2149
Practice Address - Country:US
Practice Address - Phone:937-773-3485
Practice Address - Fax:937-773-3485
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000189899OtherANTHEM INDIV PIN#-LIMA
OH000000298668OtherANTHEM INDIV PIN#-SIDNEY
OH2068873Medicaid
OH000000028161OtherANTHEM INDIV#-PIQUA
OH2068873Medicaid
OH000000298668OtherANTHEM INDIV PIN#-SIDNEY