Provider Demographics
NPI:1922046259
Name:MOORE, MICHELE A (PT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
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 1:9101 WESLEYAN RD
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3103
Mailing Address - Country:US
Mailing Address - Phone:800-603-6046
Mailing Address - Fax:317-884-3388
Practice Address - Street 1:3100 TRADITION CIR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7200
Practice Address - Country:US
Practice Address - Phone:843-654-7945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4895Medicare ID - Type UnspecifiedGROUP NUMBER