Provider Demographics
NPI:1780721761
Name:ROSZCZENKO, MARIA (PT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ROSZCZENKO
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 1:5820 N LILLEY RD
Mailing Address - Street 2:STE 6
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3691
Mailing Address - Country:US
Mailing Address - Phone:734-404-5856
Mailing Address - Fax:734-273-9361
Practice Address - Street 1:5820 N LILLEY RD
Practice Address - Street 2:STE 6
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3691
Practice Address - Country:US
Practice Address - Phone:734-404-5856
Practice Address - Fax:734-273-9361
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00100555OtherMEDICARE RAILROAD
MI0N58620OtherHAP
MI7543420OtherAETNA
MI16869OtherM-CARE
MI0H20094OtherBCBS
MI500573OtherCARE CHOICES
MI0N58620OtherHAP