MEDICARE: MARISSA MAE PETSCH

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	3848	NE

General Provider Information

NPI Number	:	1578219689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA MAE PETSCH

Provider Business Mailing Address
First Line	:	621 N FRANKLIN ST
Second Line	:
City	:	RED CLOUD
State	:	NE
Zip	:	68970-2260
Country	:	US
Telephone Number	:	402-746-5600
Fax Number	:	402-746-5687

Provider Business Practice Location Address
First Line	:	621 N FRANKLIN ST
Second Line	:
City	:	RED CLOUD
State	:	NE
Zip	:	68970-2260
Country	:	US
Telephone Number	:	402-746-5600
Fax Number	:	402-746-5687

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

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	02/28/2022

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Directions to “ MARISSA MAE PETSCH ” Practice Location

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