Provider Demographics
NPI:1174139265
Name:MOODY, MARY CAITLYN (DPT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CAITLYN
Last Name:MOODY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7065 AIRWAYS BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5874
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:960 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-3880
Practice Address - Country:US
Practice Address - Phone:662-260-3789
Practice Address - Fax:662-290-3790
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6968225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist