Provider Demographics
NPI:1003880717
Name:MOORE, TAMMARA J (DPT, OCS)
Entity type:Individual
Prefix:
First Name:TAMMARA
Middle Name:J
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 UPLAND RD
Mailing Address - Street 2:
Mailing Address - City:KENTFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2738
Mailing Address - Country:US
Mailing Address - Phone:510-823-7154
Mailing Address - Fax:
Practice Address - Street 1:100 SHORELINE HWY STE 210A
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3645
Practice Address - Country:US
Practice Address - Phone:415-729-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA154272251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT154270Medicare ID - Type Unspecified