Provider Demographics
NPI:1659770006
Name:KILEY, MOIRA KATHRINE (LATC)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:KATHRINE
Last Name:KILEY
Suffix:
Gender:F
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 THORNDIKE ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-5854
Mailing Address - Country:US
Mailing Address - Phone:978-767-6606
Mailing Address - Fax:
Practice Address - Street 1:275 CABOT ST STE 6
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4526
Practice Address - Country:US
Practice Address - Phone:978-927-8945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-21
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer