Provider Demographics
NPI:1598000127
Name:MOORE, MICHAL DESIREE
Entity Type:Individual
Prefix:
First Name:MICHAL
Middle Name:DESIREE
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 1:1940 E WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1312
Mailing Address - Country:US
Mailing Address - Phone:215-764-5782
Mailing Address - Fax:215-764-5782
Practice Address - Street 1:1940 E WALNUT LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1312
Practice Address - Country:US
Practice Address - Phone:215-764-5782
Practice Address - Fax:215-764-5782
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-08
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist