Provider Demographics
NPI:1801191655
Name:MOORE, MELISSA H (PTA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:H
Last Name:MOORE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W OMAHA ST
Mailing Address - Street 2:STE. #3
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-8120
Mailing Address - Country:US
Mailing Address - Phone:605-721-5950
Mailing Address - Fax:605-721-5940
Practice Address - Street 1:1110 W OMAHA ST
Practice Address - Street 2:STE. #3
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-8120
Practice Address - Country:US
Practice Address - Phone:605-721-5950
Practice Address - Fax:605-721-5940
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0312225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant