Provider Demographics
NPI:1295393072
Name:MOORE, MICHAEL BRYAN (PHD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BRYAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6957
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24142-6957
Mailing Address - Country:US
Mailing Address - Phone:540-831-6218
Mailing Address - Fax:
Practice Address - Street 1:445 MAPLE ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:VA
Practice Address - Zip Code:24084-2918
Practice Address - Country:US
Practice Address - Phone:540-616-8844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260006072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer