Provider Demographics
NPI:1366612384
Name:DANIELS, MARY KAY (PTA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4835
Mailing Address - Country:US
Mailing Address - Phone:850-932-6382
Mailing Address - Fax:850-932-9215
Practice Address - Street 1:1921 ORTEGA ST
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-4111
Practice Address - Country:US
Practice Address - Phone:850-936-8919
Practice Address - Fax:850-936-8936
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 19237225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant