Basic Information
| Provider Information | |||||||||
| NPI: | 1346770591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RYAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700N DELAWARE AVE APT J | ||||||||
| Address2: | |||||||||
| City: | GRAFTON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53024 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 734 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532024602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142776500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 06/19/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 13863-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.