Provider Demographics
NPI:1902011430
Name:MOORE, SUSAN (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
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 1:8859 FOX DR
Mailing Address - Street 2:#300
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80260-6899
Mailing Address - Country:US
Mailing Address - Phone:303-428-4646
Mailing Address - Fax:303-429-6255
Practice Address - Street 1:8859 FOX DR
Practice Address - Street 2:#300
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-6899
Practice Address - Country:US
Practice Address - Phone:303-428-4646
Practice Address - Fax:303-429-6255
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1804261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy