Provider Demographics
NPI:1558688010
Name:KAVANAUGH, MARY TRACEY ALYSON (PT)
Entity Type:Individual
Prefix:
First Name:MARY TRACEY
Middle Name:ALYSON
Last Name:KAVANAUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 601791
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1791
Mailing Address - Country:US
Mailing Address - Phone:704-316-1266
Mailing Address - Fax:704-316-1266
Practice Address - Street 1:14330 OAKHILL PARK LN STE 115
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3479
Practice Address - Country:US
Practice Address - Phone:704-316-1280
Practice Address - Fax:704-316-1266
Is Sole Proprietor?:No
Enumeration Date:2010-04-23
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP9204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist