Provider Demographics
NPI:1790093789
Name:MOORE, MARY ELLEN (DPT)
Entity Type:Individual
Prefix:DR
First Name:MARY ELLEN
Middle Name:
Last Name:MOORE
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 1:220 ROSS DR
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1640
Mailing Address - Country:US
Mailing Address - Phone:908-578-9514
Mailing Address - Fax:
Practice Address - Street 1:33 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07432-1401
Practice Address - Country:US
Practice Address - Phone:800-888-2250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01322900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist