Provider Demographics
NPI:1083895080
Name:MCCLERNON, MAUREEN A (PT)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:A
Last Name:MCCLERNON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:A
Other - Last Name:MCCLERNON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:35 OLD KINGS RD N
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8227
Mailing Address - Country:US
Mailing Address - Phone:389-445-5555
Mailing Address - Fax:386-445-9800
Practice Address - Street 1:35 OLD KINGS RD N
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8227
Practice Address - Country:US
Practice Address - Phone:389-445-5555
Practice Address - Fax:386-445-9800
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0010163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist