Provider Demographics
NPI:1710635578
Name:MOORE, JAMES PETER (PTA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PETER
Last Name:MOORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 N ANNIE GLIDDEN RD
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1207
Mailing Address - Country:US
Mailing Address - Phone:815-217-0342
Mailing Address - Fax:
Practice Address - Street 1:DEKALB COUNTY REHAB
Practice Address - Street 2:2600 N ANNIE GLIDDEN RD
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115
Practice Address - Country:US
Practice Address - Phone:815-758-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.008658225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant