Provider Demographics
NPI:1871005967
Name:MOORE, JOYCE L (ATC/PTA)
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:ATC/PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13996 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8719
Mailing Address - Country:US
Mailing Address - Phone:530-205-8870
Mailing Address - Fax:
Practice Address - Street 1:11392 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:PENN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95946-9001
Practice Address - Country:US
Practice Address - Phone:530-432-9660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA3774225200000X
CA0000809672255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer