Provider Demographics
NPI:1497023097
Name:MOORE, LACIE (PTA)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:
Other - Last Name:DER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:6011 UNIVERSITY BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6104
Mailing Address - Country:US
Mailing Address - Phone:410-203-0391
Mailing Address - Fax:410-203-2707
Practice Address - Street 1:6011 UNIVERSITY BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-6074
Practice Address - Country:US
Practice Address - Phone:410-203-0391
Practice Address - Fax:410-203-2707
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3664225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant