Provider Demographics
NPI:1720516040
Name:MALE, MARIANNE WILSON (PT)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:WILSON
Last Name:MALE
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 1:1122 ROUNDELAY RD E
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2029
Mailing Address - Country:US
Mailing Address - Phone:614-738-5005
Mailing Address - Fax:
Practice Address - Street 1:1481 W TOWN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-1379
Practice Address - Country:US
Practice Address - Phone:614-276-8231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03241225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist