Provider Demographics
NPI:1497465306
Name:MAURO, MALCOLM (PT, DPT)
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:MAURO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 KENMOOR AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:7253 S 76TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9041
Practice Address - Country:US
Practice Address - Phone:414-425-9700
Practice Address - Fax:414-425-9701
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WICP049267T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist