Provider Demographics
NPI:1508874892
Name:BARONE, MOIRA M (PT, ATC)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:M
Last Name:BARONE
Suffix:
Gender:F
Credentials:PT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TERMINAL DR STE 4B
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2296
Mailing Address - Country:US
Mailing Address - Phone:618-288-6361
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:4 COUGAR DR STE A
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034
Practice Address - Country:US
Practice Address - Phone:618-288-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1105248225100000X
WI9939225100000X
IL070014287225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40376200Medicaid
WI46236-0097Medicare PIN
WI68635-0372Medicare PIN
WI01994-0097Medicare PIN
WI40376200Medicaid