Provider Demographics
NPI:1659776227
Name:MOORE, MOLLY (PTA)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
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 1:276 GREEN AVE EXT
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17044-9707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:276 GREEN AVE EXT
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:PA
Practice Address - Zip Code:17044-9707
Practice Address - Country:US
Practice Address - Phone:717-242-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI002288225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant