Provider Demographics
NPI:1114937976
Name:MOREAU, MARY KATHERINE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHERINE
Last Name:MOREAU
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:KATHERINE
Other - Last Name:HEMSTREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4 JACKSON ST NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4925
Mailing Address - Country:US
Mailing Address - Phone:850-862-7227
Mailing Address - Fax:850-862-2421
Practice Address - Street 1:4 JACKSON ST NE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4925
Practice Address - Country:US
Practice Address - Phone:850-862-7227
Practice Address - Fax:850-862-2421
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT201312251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics