Basic Information
| Provider Information | |||||||||
| NPI: | 1700075694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAROSE | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7517 W COLDSPRING RD | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532202814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143276603 | ||||||||
| FaxNumber: | 4143275411 | ||||||||
| Practice Location | |||||||||
| Address1: | 7517 W COLDSPRING RD | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532202814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143276603 | ||||||||
| FaxNumber: | 4143275411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2007 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
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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 | 225200000X | 1415-019 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 36146200 | 05 | WI | MEDICAID |