MEDICARE: KAITLYN MOSHER PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		MI

General Provider Information

NPI Number	:	1417596032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAITLYN MOSHER PT, DPT

Provider Business Mailing Address
First Line	:	29255 NORTHWESTERN HWY STE 300
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48034-5742
Country	:	US
Telephone Number	:	248-353-1234
Fax Number	:	248-353-1211

Provider Business Practice Location Address
First Line	:	1071 N CAMPBELL RD
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-1519
Country	:	US
Telephone Number	:	248-353-1234
Fax Number	:	248-353-1211

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2019
Last Update Date	:	07/19/2021

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