Provider Demographics
NPI:1659983989
Name:MOORE, HAILEE RENAE (LPTA)
Entity Type:Individual
Prefix:
First Name:HAILEE
Middle Name:RENAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9150 ONSTED HWY
Mailing Address - Street 2:
Mailing Address - City:ONSTED
Mailing Address - State:MI
Mailing Address - Zip Code:49265-9707
Mailing Address - Country:US
Mailing Address - Phone:517-902-3674
Mailing Address - Fax:
Practice Address - Street 1:951 HICKORY CREEK DR
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-2327
Practice Address - Country:US
Practice Address - Phone:734-206-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502006110225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant