Provider Demographics
NPI:1255380853
Name:MOORE, LAURA SIMCHAK (MPT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:SIMCHAK
Last Name:MOORE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:MRS
Other - First Name:LAUR
Other - Middle Name:SIMCHAK
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MPT
Mailing Address - Street 1:1530 E ROCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85024-2958
Mailing Address - Country:US
Mailing Address - Phone:602-750-1448
Mailing Address - Fax:
Practice Address - Street 1:3401 N 67TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-4517
Practice Address - Country:US
Practice Address - Phone:623-691-4032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5964225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist