Provider Demographics
NPI:1700026002
Name:MORAN, LYNNE (PT)
Entity Type:Individual
Prefix:MRS
First Name:LYNNE
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:C
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1107 E MICHIGAN AVE # 1
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-1311
Mailing Address - Country:US
Mailing Address - Phone:989-348-3027
Mailing Address - Fax:989-348-4246
Practice Address - Street 1:1107 E MICHIGAN AVE # 1
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1311
Practice Address - Country:US
Practice Address - Phone:989-348-3027
Practice Address - Fax:989-348-4246
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010013242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4775287Medicaid
MI4775287Medicaid