Provider Demographics
NPI:1649587486
Name:MOORE, ELAINE MARIE (DPT)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:MARIE
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 1:12334 POTATO HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13309-4836
Mailing Address - Country:US
Mailing Address - Phone:315-527-6469
Mailing Address - Fax:
Practice Address - Street 1:110 FORD ST
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:NY
Practice Address - Zip Code:13309-1204
Practice Address - Country:US
Practice Address - Phone:315-942-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0295162251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics