Provider Demographics
NPI:1770168106
Name:AMYOT, MARY CATHERINE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:AMYOT
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 1:6975 LAKEPORT DR
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-2210
Mailing Address - Country:US
Mailing Address - Phone:586-491-3923
Mailing Address - Fax:
Practice Address - Street 1:1411 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5480
Practice Address - Country:US
Practice Address - Phone:810-496-8705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-17
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003784225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist