Provider Demographics
NPI:1689202186
Name:MOORE-MOSBY, MARILYN ROSE (DPT)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:ROSE
Last Name:MOORE-MOSBY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4239 S FARM ROAD 131
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-1042
Mailing Address - Country:US
Mailing Address - Phone:417-840-4164
Mailing Address - Fax:
Practice Address - Street 1:3545 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-269-5500
Practice Address - Fax:417-269-5508
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015020520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist