Provider Demographics
NPI:1689961138
Name:MORAHAN, KRISTLE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KRISTLE
Middle Name:MARIE
Last Name:MORAHAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 WENMORE LN
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2831
Mailing Address - Country:US
Mailing Address - Phone:631-473-0426
Mailing Address - Fax:
Practice Address - Street 1:77 ROUTE 112 STE F
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1230
Practice Address - Country:US
Practice Address - Phone:631-207-2370
Practice Address - Fax:631-758-1748
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist