Provider Demographics
NPI:1417976754
Name:MOORE, LISA KATHLEEN (PTA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:KATHLEEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11206 ROSARITA DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3210
Mailing Address - Country:US
Mailing Address - Phone:909-435-1753
Mailing Address - Fax:
Practice Address - Street 1:9116 FOOTHILL BLVD STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6564
Practice Address - Country:US
Practice Address - Phone:909-941-7177
Practice Address - Fax:909-941-1717
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT2345225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant