Provider Demographics
NPI:1184030900
Name:SIBBALUCA, MOIRA
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:SIBBALUCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ROMINER CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DAZELL
Mailing Address - State:IL
Mailing Address - Zip Code:61320
Mailing Address - Country:US
Mailing Address - Phone:815-326-5924
Mailing Address - Fax:
Practice Address - Street 1:4231 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1193
Practice Address - Country:US
Practice Address - Phone:815-326-5924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist