Provider Demographics
NPI:1770233439
Name:CANTRELL, MARY CLAIRE DANIELLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARY CLAIRE
Middle Name:DANIELLE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:MARY CLAIRE
Other - Middle Name:DANIELLE
Other - Last Name:LAHAIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:18 E POINT DR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-1405
Mailing Address - Country:US
Mailing Address - Phone:678-640-8630
Mailing Address - Fax:
Practice Address - Street 1:5 LAKE ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31411-2983
Practice Address - Country:US
Practice Address - Phone:912-295-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT013561225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist