Provider Demographics
NPI:1396872230
Name:MOYER, MARY AN GRACIE (PT)
Entity type:Individual
Prefix:MRS
First Name:MARY AN
Middle Name:GRACIE
Last Name:MOYER
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 1:38SWCUTOFF B
Mailing Address - Street 2:
Mailing Address - City:NORTHBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01532-2159
Mailing Address - Country:US
Mailing Address - Phone:508-393-0890
Mailing Address - Fax:774-987-3005
Practice Address - Street 1:38 SW CUTOFF
Practice Address - Street 2:
Practice Address - City:NORTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01532-2159
Practice Address - Country:US
Practice Address - Phone:508-393-0890
Practice Address - Fax:774-987-3005
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA20-8915668OtherEMPLOYER IDENTIFICATION #