Provider Demographics
NPI:1205104445
Name:MOORE, LEILA C (DPT)
Entity type:Individual
Prefix:MRS
First Name:LEILA
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:MS
Other - First Name:LEILA
Other - Middle Name:
Other - Last Name:CHANNAOUI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4651 NIXON PARK DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-9759
Mailing Address - Country:US
Mailing Address - Phone:315-492-0592
Mailing Address - Fax:315-458-2975
Practice Address - Street 1:19 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-2501
Practice Address - Country:US
Practice Address - Phone:315-635-5000
Practice Address - Fax:315-635-3663
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY877094448225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist