Provider Demographics
NPI:1477897643
Name:MOORE, LORETTA (PTA)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
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 1:9 WAVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1231
Mailing Address - Country:US
Mailing Address - Phone:855-584-5845
Mailing Address - Fax:855-584-7323
Practice Address - Street 1:9 WAVELAND AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1231
Practice Address - Country:US
Practice Address - Phone:855-584-5845
Practice Address - Fax:855-584-7323
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA01777225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant