=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114937976
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY KATHERINE MOREAU PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 JACKSON ST NE
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32548-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-862-7227
-----------------------------------------------------
Fax | 850-862-2421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 JACKSON ST NE
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32548-4925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-862-7227
-----------------------------------------------------
Fax | 850-862-2421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | PT20131
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------