Provider Demographics
NPI:1386406072
Name:MOREAN, MAC (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:MAC
Middle Name:
Last Name:MOREAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:DR
Other - First Name:MACKENZIE
Other - Middle Name:
Other - Last Name:MOREAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:650 SOUTH AVE E
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-7011
Mailing Address - Country:US
Mailing Address - Phone:406-425-3641
Mailing Address - Fax:
Practice Address - Street 1:2651 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59804-6405
Practice Address - Country:US
Practice Address - Phone:406-728-9162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-27350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist