Provider Demographics
NPI:1679541262
Name:MODER, MAUREEN LEE (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:LEE
Last Name:MODER
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 SW 161ST ST
Mailing Address - Street 2:
Mailing Address - City:VILLAGE OF PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3737
Mailing Address - Country:US
Mailing Address - Phone:305-255-6869
Mailing Address - Fax:
Practice Address - Street 1:6341 SUNSET DR
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4842
Practice Address - Country:US
Practice Address - Phone:305-662-5924
Practice Address - Fax:305-663-4442
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0006317225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist