Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251P0200X | Physical Therapist - Pediatrics | PT20131 | FL |
NPI | 1114937976 |
---|---|
Provider Name | Mrs. Mary Katherine Moreau |
First Address | Fort Walton Beach, FL 32548-4925 |
Second Address | Fort Walton Beach, FL 32548-4925 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/08/2006 |
Last Update Date | 08/07/2007 |