Provider Demographics
NPI:1326177882
Name:MOORE, LAURA OLSEN (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:OLSEN
Last Name:MOORE
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:PO BOX 16937
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24209-6937
Mailing Address - Country:US
Mailing Address - Phone:276-591-5484
Mailing Address - Fax:276-591-5477
Practice Address - Street 1:136 BRISTOL EAST RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24202-5500
Practice Address - Country:US
Practice Address - Phone:276-591-5484
Practice Address - Fax:276-591-5477
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305001916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist