Provider Demographics
NPI:1174623334
Name:KOSOBUCKI, MARLENE (PT)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:KOSOBUCKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:
Other - Last Name:KOSOBUCKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1200 GRANT BLVD W
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1042
Mailing Address - Country:US
Mailing Address - Phone:651-565-4531
Mailing Address - Fax:
Practice Address - Street 1:1200 GRANT BLVD W
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-1042
Practice Address - Country:US
Practice Address - Phone:651-565-4531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40104500Medicaid
WI40104500Medicaid
WI005083450Medicare ID - Type Unspecified