Provider Demographics
NPI:1659097780
Name:ROOT, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ROOT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:GAYS MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:54631-0092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 ATLEY ST
Practice Address - Street 2:
Practice Address - City:SOLDIERS GROVE
Practice Address - State:WI
Practice Address - Zip Code:54655-8505
Practice Address - Country:US
Practice Address - Phone:507-571-0585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2436-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist