Provider Demographics
NPI:1790742021
Name:MOORE, COLEEN LEANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:COLEEN
Middle Name:LEANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0841
Mailing Address - Country:US
Mailing Address - Phone:870-743-5573
Mailing Address - Fax:870-743-5974
Practice Address - Street 1:1801 FOREST HILLS BLVD
Practice Address - Street 2:STE 205
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72715
Practice Address - Country:US
Practice Address - Phone:479-855-9348
Practice Address - Fax:479-855-9358
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
5T496OtherBCBS
AR5T496Medicare ID - Type Unspecified