Provider Demographics
NPI:1245876697
Name:JOSEPH, MARYLOU (PTA)
Entity type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3176 HADDEN RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48306-1132
Mailing Address - Country:US
Mailing Address - Phone:586-524-4183
Mailing Address - Fax:
Practice Address - Street 1:1663 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2169
Practice Address - Country:US
Practice Address - Phone:248-327-6619
Practice Address - Fax:248-327-6628
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002185225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant