Provider Demographics
NPI:1467799239
Name:MOORE, LETITIA S (CMT)
Entity Type:Individual
Prefix:
First Name:LETITIA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:TISH
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1312 EMIGH ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4220
Mailing Address - Country:US
Mailing Address - Phone:970-481-1633
Mailing Address - Fax:
Practice Address - Street 1:1113 STONEY HILL RD
Practice Address - Street 2:STE C
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1372
Practice Address - Country:US
Practice Address - Phone:970-481-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-13
Last Update Date:2013-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist