Provider Demographics
NPI:1629117684
Name:MOORE, TERESA R (PTA)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:R
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 1:703 CRESTVIEW CIR W
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-3536
Mailing Address - Country:US
Mailing Address - Phone:352-748-3336
Mailing Address - Fax:
Practice Address - Street 1:703 CRESTVIEW CIR W
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-3536
Practice Address - Country:US
Practice Address - Phone:352-748-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20405225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant