Healthcare Provider Details

I. General information

NPI: 1578295911
Provider Name (Legal Business Name): MARY GANZ PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1445 GALAXY DR NE STE 301
LACEY WA
98516-4754
US

IV. Provider business mailing address

26293 FALCON LN
EVANS MILLS NY
13637-3442
US

V. Phone/Fax

Practice location:
  • Phone: 360-456-1444
  • Fax:
Mailing address:
  • Phone: 717-916-3222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61330682
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number048636
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: