Provider Demographics
NPI:1912397050
Name:MOORE, MARISSA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 ASHFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-5540
Mailing Address - Country:US
Mailing Address - Phone:336-209-4247
Mailing Address - Fax:
Practice Address - Street 1:5610 BETHELVIEW RD STE 400
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-7523
Practice Address - Country:US
Practice Address - Phone:770-781-8851
Practice Address - Fax:770-781-8227
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0118162251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic