Provider Demographics
NPI:1689838773
Name:KOUKOS, MARY JULIA (MSPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JULIA
Last Name:KOUKOS
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BRIDGE ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35811-9761
Mailing Address - Country:US
Mailing Address - Phone:256-746-0555
Mailing Address - Fax:
Practice Address - Street 1:500 SAINT CLAIR AVE SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-5021
Practice Address - Country:US
Practice Address - Phone:256-539-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3943225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist