Provider Demographics
NPI:1306480165
Name:MORALES, MARY-GRACE (PT, DPT)
Entity type:Individual
Prefix:
First Name:MARY-GRACE
Middle Name:
Last Name:MORALES
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 NEWNAN CROSSING BLVD E
Mailing Address - Street 2:APARTMENT 5101
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 SPRING ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2824
Practice Address - Country:US
Practice Address - Phone:912-722-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-04
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012146225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist