Healthcare Provider Details

I. General information

NPI: 1700041480
Provider Name (Legal Business Name): MARY LYNNE BISONE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 10/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 17TH ST
SARASOTA FL
34235-1843
US

IV. Provider business mailing address

4630 17TH ST
SARASOTA FL
34235-1843
US

V. Phone/Fax

Practice location:
  • Phone: 941-487-5400
  • Fax: 941-487-5430
Mailing address:
  • Phone: 941-487-5400
  • Fax: 941-487-5430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberPT32625
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number08351-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberPT32625
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT32625
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: