Provider Demographics
NPI:1407294150
Name:MOORE, REBECCA WALLIS
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:WALLIS
Last Name:MOORE
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 1:414 ARNOLD AVE
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-3838
Mailing Address - Country:US
Mailing Address - Phone:843-209-6792
Mailing Address - Fax:
Practice Address - Street 1:2825 CARTER RD
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1712
Practice Address - Country:US
Practice Address - Phone:803-469-7007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7052225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist