Provider Demographics
NPI:1497235501
Name:MOORE, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-3989
Mailing Address - Country:US
Mailing Address - Phone:903-880-8705
Mailing Address - Fax:
Practice Address - Street 1:1351 S ELM ST
Practice Address - Street 2:
Practice Address - City:KEMP
Practice Address - State:TX
Practice Address - Zip Code:75143-7713
Practice Address - Country:US
Practice Address - Phone:903-498-8073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2132009225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant