Provider Demographics
NPI:1679179014
Name:MOORE, MARQUITA (LMT)
Entity Type:Individual
Prefix:
First Name:MARQUITA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MARQUITA
Other - Middle Name:
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:950 HENDERSON ST APT 1206
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-3586
Mailing Address - Country:US
Mailing Address - Phone:682-305-4882
Mailing Address - Fax:
Practice Address - Street 1:100 E 15TH ST STE 117
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-6522
Practice Address - Country:US
Practice Address - Phone:682-305-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-10
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT131029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist