Provider Demographics
NPI:1700041480
Name:BISONE, MARY LYNNE (PT)
Entity Type:Individual
Prefix:
First Name:MARY LYNNE
Middle Name:
Last Name:BISONE
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 1:4630 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34235-1843
Mailing Address - Country:US
Mailing Address - Phone:941-487-5400
Mailing Address - Fax:941-487-5430
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-487-5400
Practice Address - Fax:941-487-5430
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-22
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT32625222Q00000X, 252Y00000X, 225100000X
NY08351-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1982739819OtherPROVIDER NUMBER
FL021882200Medicaid
FL022608000Medicaid