Healthcare Provider Details

I. General information

NPI: 1346770591
Provider Name (Legal Business Name): MARY KATHLEEN RYAN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2017
Last Update Date: 06/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 N JACKSON ST
MILWAUKEE WI
53202-4602
US

IV. Provider business mailing address

700N DELAWARE AVE APT J
GRAFTON WI
53024
US

V. Phone/Fax

Practice location:
  • Phone: 414-277-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13863-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: