Provider Demographics
NPI:1871539171
Name:HALL, MARY LAURA (MPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LAURA
Last Name:HALL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 PRAIRIE HEIGHTS DR, STE 101
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-848-6629
Mailing Address - Fax:608-848-6629
Practice Address - Street 1:411 PRAIRIE HEIGHTS DR STE 101
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-848-6628
Practice Address - Fax:608-848-6629
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10129-0242251X0800X
WI10129-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI81600 0002Medicare ID - Type Unspecified