Provider Demographics
NPI:1083891295
Name:MOYER, MELISSA A (PT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MOYER
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 1:850 43RD AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-8401
Mailing Address - Country:US
Mailing Address - Phone:309-743-2070
Mailing Address - Fax:309-743-2073
Practice Address - Street 1:520 VALLEY VIEW DR STE 200
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-797-0866
Practice Address - Fax:309-797-0872
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA004170225100000X
IL070-016452225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA004170OtherIOWA PT LICENSE NUMBER
IL070-016452OtherILLINOIS PT LICENSE NO
IL070-016452OtherILLINOIS PT LICENSE NO
IA004170OtherIOWA PT LICENSE NUMBER