Provider Demographics
NPI:1437509429
Name:MOORE, THOMAS ANTHONY
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ANTHONY
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38571-0755
Mailing Address - Country:US
Mailing Address - Phone:904-806-5654
Mailing Address - Fax:
Practice Address - Street 1:180 THOMPSON RD
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38571-0755
Practice Address - Country:US
Practice Address - Phone:904-806-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 16838225X00000X
TX117184225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist