Provider Demographics
NPI:1144776717
Name:MOORE, REBECCA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:LYNN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-2424
Mailing Address - Country:US
Mailing Address - Phone:608-263-8060
Mailing Address - Fax:608-262-7679
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792
Practice Address - Country:US
Practice Address - Phone:608-263-8060
Practice Address - Fax:608-262-7679
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13443-24225100000X
IL070-022170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist