Provider Demographics
NPI:1104534312
Name:CROMBEZ, MARY ROSE (MT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ROSE
Last Name:CROMBEZ
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9615 INGRAM ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-2817
Mailing Address - Country:US
Mailing Address - Phone:734-522-2967
Mailing Address - Fax:
Practice Address - Street 1:9615 INGRAM ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2817
Practice Address - Country:US
Practice Address - Phone:734-522-2967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010654172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist