Provider Demographics
NPI:1962656629
Name:WISINSKI, MARY KAE (PT)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KAE
Last Name:WISINSKI
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 1:1256 RIVERTON DR
Mailing Address - Street 2:
Mailing Address - City:MUKWONAGO
Mailing Address - State:WI
Mailing Address - Zip Code:53149-1054
Mailing Address - Country:US
Mailing Address - Phone:262-363-2566
Mailing Address - Fax:
Practice Address - Street 1:13700 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-9521
Practice Address - Country:US
Practice Address - Phone:262-797-4600
Practice Address - Fax:262-797-4616
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6041024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist