Provider Demographics
NPI:1679833438
Name:MOORE, WHITNEY
Entity Type:Individual
Prefix:
First Name:WHITNEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2012 IRONWOOD CIRCLE, SUITE 230
Mailing Address - Street 2:CIRCLE CENTRE BUILDING,
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635
Mailing Address - Country:US
Mailing Address - Phone:574-387-4049
Mailing Address - Fax:
Practice Address - Street 1:2012 IRONWOOD CIRCLE, SUITE 230
Practice Address - Street 2:CIRCLE CENTRE BUILDING,
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635
Practice Address - Country:US
Practice Address - Phone:574-387-4049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004421A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant