Provider Demographics
NPI:1609172295
Name:DE ZEE, MARY GRACE (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:DE ZEE
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 1:1115 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-2104
Mailing Address - Country:US
Mailing Address - Phone:608-325-6610
Mailing Address - Fax:
Practice Address - Street 1:402 S CENTER ST
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:IL
Practice Address - Zip Code:61024-9590
Practice Address - Country:US
Practice Address - Phone:815-248-2151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-31
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5067-24225100000X
IL070.011905225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist