Provider Demographics
NPI:1669503991
Name:DELA ROSA, MARY JOY (RPT)
Entity Type:Individual
Prefix:
First Name:MARY JOY
Middle Name:
Last Name:DELA ROSA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20005 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:391 N STATE RD
Practice Address - Street 2:SUITE A
Practice Address - City:OTISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48463-9486
Practice Address - Country:US
Practice Address - Phone:810-631-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist