MEDICARE: MARY BRAGANZA PHYSICAL THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	551010155	MI
2	225100000X	Physical Therapist	5501010155	MI

General Provider Information

NPI Number	:	1104321355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BRAGANZA PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	49461 OXLEY RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1520
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	34643 KETSIN DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-5235
Country	:	US
Telephone Number	:	586-978-2280
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/29/2018
Last Update Date	:	03/29/2018

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