Provider Demographics
NPI:1225232267
Name:MASSICOTTE, MOIRA MICHELLE (PT)
Entity Type:Individual
Prefix:MRS
First Name:MOIRA
Middle Name:MICHELLE
Last Name:MASSICOTTE
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 1:1116 TEASEL LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-9778
Mailing Address - Country:US
Mailing Address - Phone:214-478-5824
Mailing Address - Fax:
Practice Address - Street 1:1116 TEASEL LN
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-9778
Practice Address - Country:US
Practice Address - Phone:214-478-5824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL70015731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist