Provider Demographics
NPI:1790877686
Name:MOORE, LISA ANN (MSPT, OCS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306-A HIGH STREET
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301
Mailing Address - Country:US
Mailing Address - Phone:413-773-3379
Mailing Address - Fax:413-772-2705
Practice Address - Street 1:306-A HIGH STREET
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301
Practice Address - Country:US
Practice Address - Phone:413-773-3379
Practice Address - Fax:413-772-2705
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0396460Medicaid
MA470239OtherTUFTS
MAY68106OtherBCBS
MA1294660OtherFALLON
MAY68833Medicare ID - Type Unspecified