Provider Demographics
NPI:1396786802
Name:MARIK, MAIRA S (PT)
Entity type:Individual
Prefix:
First Name:MAIRA
Middle Name:S
Last Name:MARIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:14555 W NATIONAL AVE
Practice Address - Street 2:SUITE 170
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4494
Practice Address - Country:US
Practice Address - Phone:262-827-3636
Practice Address - Fax:262-827-3626
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9827-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00734839OtherRR MEDICARE
WI40385700Medicaid
WI40385700Medicaid
WIP00734839OtherRR MEDICARE