Provider Demographics
NPI:1770508764
Name:MARZANO, MARY KATHERINE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:MARZANO
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 1:3719 N 86TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2829
Mailing Address - Country:US
Mailing Address - Phone:414-463-9882
Mailing Address - Fax:
Practice Address - Street 1:15350 W NATIONAL AVE
Practice Address - Street 2:SUITE #109
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5158
Practice Address - Country:US
Practice Address - Phone:262-789-0970
Practice Address - Fax:262-789-7817
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3199-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI36126500Medicaid