Provider Demographics
NPI:1053444505
Name:MOONEY, MARY STAVRIDIS (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:STAVRIDIS
Last Name:MOONEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 MERRIVALE DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4448
Mailing Address - Country:US
Mailing Address - Phone:631-265-3027
Mailing Address - Fax:
Practice Address - Street 1:66 MERRIVALE DR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4448
Practice Address - Country:US
Practice Address - Phone:631-265-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006678OtherPHYSICAL THERAPY LICENSE
NY5913183OtherCERTIFICATE NUMBER