Provider Demographics
NPI:1639326184
Name:MOORE, MARY MELISSA (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MELISSA
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:MELISSA
Other - Last Name:ST. CLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11031 JONES RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9660
Mailing Address - Country:US
Mailing Address - Phone:269-684-7130
Mailing Address - Fax:
Practice Address - Street 1:2500 NILES RD
Practice Address - Street 2:SUITE 3
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-3237
Practice Address - Country:US
Practice Address - Phone:269-428-1550
Practice Address - Fax:269-428-6762
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist