Provider Demographics
NPI:1063777654
Name:MAESCH, MARY MARKLEY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARKLEY
Last Name:MAESCH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:MARKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:215 E MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1681
Mailing Address - Country:US
Mailing Address - Phone:248-349-9339
Mailing Address - Fax:248-349-9342
Practice Address - Street 1:215 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1681
Practice Address - Country:US
Practice Address - Phone:248-349-9339
Practice Address - Fax:248-349-9342
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005097225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist