Provider Demographics
NPI:1265833149
Name:MOORE, KASEY (LMT)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 SE BAYA DR STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-8007
Mailing Address - Country:US
Mailing Address - Phone:386-400-3140
Mailing Address - Fax:
Practice Address - Street 1:2230 SE BAYA DR STE 103
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-8007
Practice Address - Country:US
Practice Address - Phone:386-400-3140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA73189225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist