Provider Demographics
NPI:1053507186
Name:MOORE, TERESSA S (LMT)
Entity Type:Individual
Prefix:
First Name:TERESSA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14317 DUCKFLAT RD SE
Mailing Address - Street 2:
Mailing Address - City:TURNER
Mailing Address - State:OR
Mailing Address - Zip Code:97392-9744
Mailing Address - Country:US
Mailing Address - Phone:503-884-6254
Mailing Address - Fax:
Practice Address - Street 1:6395 KEIZER STATION BLVD NE
Practice Address - Street 2:STE 103
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-2305
Practice Address - Country:US
Practice Address - Phone:503-589-1597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13017225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist