Provider Demographics
NPI:1639801731
Name:MOORE, MONTANA (DPT)
Entity type:Individual
Prefix:
First Name:MONTANA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 SOUTHLEA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-3640
Mailing Address - Country:US
Mailing Address - Phone:937-681-4676
Mailing Address - Fax:
Practice Address - Street 1:1680 W IRVINGTON RD STE 130
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-4174
Practice Address - Country:US
Practice Address - Phone:520-623-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCP029799T225100000X
OHPT019879225100000X
AZCP036860T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist