Provider Demographics
NPI:1740279769
Name:HANSEN, MARY S (PT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:HANSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:719 WILLMOR ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4068
Mailing Address - Country:US
Mailing Address - Phone:262-752-5985
Mailing Address - Fax:
Practice Address - Street 1:6754 LINDERMANN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406-5603
Practice Address - Country:US
Practice Address - Phone:262-635-3300
Practice Address - Fax:262-635-3303
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4095-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist