Provider Demographics
NPI:1689844789
Name:MOORE, AUDRA (PT)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:
Other - Last Name:GALLUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:200 GASTON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-2739
Mailing Address - Country:US
Mailing Address - Phone:203-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:200 GASTON AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2739
Practice Address - Country:US
Practice Address - Phone:203-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302178000Medicaid