Provider Demographics
NPI:1780716605
Name:BORTON, MARY JOY (PT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JOY
Last Name:BORTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:JOY
Other - Last Name:GEROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:27477 HIGHWAY 64
Mailing Address - Street 2:SUITE C
Mailing Address - City:CORNELL
Mailing Address - State:WI
Mailing Address - Zip Code:54732-5222
Mailing Address - Country:US
Mailing Address - Phone:715-864-5394
Mailing Address - Fax:715-239-0556
Practice Address - Street 1:27477 HIGHWAY 64
Practice Address - Street 2:SUITE C
Practice Address - City:CORNELL
Practice Address - State:WI
Practice Address - Zip Code:54732-5222
Practice Address - Country:US
Practice Address - Phone:715-864-5394
Practice Address - Fax:715-239-0556
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10210225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40452000Medicaid