Provider Demographics
NPI:1215425202
Name:HEGARTY, MARY KATHERINE (PT)
Entity type:Individual
Prefix:
First Name:MARY KATHERINE
Middle Name:
Last Name:HEGARTY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 HIGHWAY 260 STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5851
Mailing Address - Country:US
Mailing Address - Phone:928-532-1221
Mailing Address - Fax:
Practice Address - Street 1:4830 HIGHWAY 260 STE 105
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5851
Practice Address - Country:US
Practice Address - Phone:928-532-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist