Provider Demographics
NPI:1609140979
Name:MOORE, TABITHA JANE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:TABITHA
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8616 FOX HAVEN CHASE
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-2973
Mailing Address - Country:US
Mailing Address - Phone:414-429-4380
Mailing Address - Fax:
Practice Address - Street 1:3415 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-1924
Practice Address - Country:US
Practice Address - Phone:262-657-6175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI247-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant