Provider Demographics
NPI:1073512208
Name:MOORE, JOANNE Z (PT, DHS, OCS)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:Z
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DHS, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 88
Mailing Address - Street 2:
Mailing Address - City:EAST LYME
Mailing Address - State:CT
Mailing Address - Zip Code:06333-0088
Mailing Address - Country:US
Mailing Address - Phone:860-739-4497
Mailing Address - Fax:860-739-7256
Practice Address - Street 1:131 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:EAST LYME
Practice Address - State:CT
Practice Address - Zip Code:06333-1605
Practice Address - Country:US
Practice Address - Phone:860-739-4497
Practice Address - Fax:860-739-7256
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4105806Medicaid