Provider Demographics
NPI:1952032005
Name:MOORE, SHANDRA COLLEEN
Entity Type:Individual
Prefix:
First Name:SHANDRA
Middle Name:COLLEEN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 EDGECLIFF DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-7416
Mailing Address - Country:US
Mailing Address - Phone:817-773-4703
Mailing Address - Fax:
Practice Address - Street 1:2365 PATRIOT HTS
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-5122
Practice Address - Country:US
Practice Address - Phone:719-667-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant