Provider Demographics
NPI:1578173316
Name:MOORE, STEPHANIE JEAN (DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 S NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUGAR CREEK
Mailing Address - State:MO
Mailing Address - Zip Code:64054-1052
Mailing Address - Country:US
Mailing Address - Phone:760-662-4887
Mailing Address - Fax:
Practice Address - Street 1:2800 CLAY EDWARDS DR
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3220
Practice Address - Country:US
Practice Address - Phone:816-691-1795
Practice Address - Fax:816-346-7795
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017022453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist