Provider Demographics
NPI:1134492093
Name:MOORE, CASEY BLYTHE (MS, ATC, SCAT)
Entity Type:Individual
Prefix:MS
First Name:CASEY
Middle Name:BLYTHE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, ATC, SCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7863 CHAMPION WAY
Mailing Address - Street 2:UNIT A
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-2210
Mailing Address - Country:US
Mailing Address - Phone:828-260-1308
Mailing Address - Fax:
Practice Address - Street 1:3300 PALMETTO HWY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29613-0001
Practice Address - Country:US
Practice Address - Phone:828-260-1308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1258390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program