Provider Demographics
NPI:1467889758
Name:WILLIAMS-MOORE, EDNA MARIE (LMT)
Entity Type:Individual
Prefix:MS
First Name:EDNA
Middle Name:MARIE
Last Name:WILLIAMS-MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2549 E 55TH PL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3525
Mailing Address - Country:US
Mailing Address - Phone:317-542-7680
Mailing Address - Fax:317-253-7380
Practice Address - Street 1:2549 E 55TH PL
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-3525
Practice Address - Country:US
Practice Address - Phone:317-542-7680
Practice Address - Fax:317-253-7380
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20902678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist