Provider Demographics
NPI:1194717660
Name:MERCURIS, KATHERINE LOUISE (PT)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LOUISE
Last Name:MERCURIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:LOUISE
Other - Last Name:MERCURIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:3200 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-4104
Mailing Address - Country:US
Mailing Address - Phone:515-271-1717
Mailing Address - Fax:515-271-7185
Practice Address - Street 1:3200 GRAND AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50312-4104
Practice Address - Country:US
Practice Address - Phone:515-271-1717
Practice Address - Fax:515-271-7185
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00830225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0232843Medicaid
IA650020383OtherRR MEDICARE
IAI1802Medicare PIN
P29406Medicare UPIN