Provider Demographics
NPI:1780183202
Name:MORIARTY, MARY CAITLIN
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CAITLIN
Last Name:MORIARTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19415 SCHOONER CT NE
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-8590
Mailing Address - Country:US
Mailing Address - Phone:360-620-9113
Mailing Address - Fax:
Practice Address - Street 1:190 SW BRUMBACK ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6899
Practice Address - Country:US
Practice Address - Phone:360-620-9113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer