Provider Demographics
NPI:1700445251
Name:MOORE, CASEY LYNN (MS, SCAT, ATC)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, SCAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 YELLOW MOUNTAIN RD SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-6437
Mailing Address - Country:US
Mailing Address - Phone:540-915-5725
Mailing Address - Fax:
Practice Address - Street 1:1300 BRUSHY CREEK RD
Practice Address - Street 2:
Practice Address - City:TAYLORS
Practice Address - State:SC
Practice Address - Zip Code:29687-4007
Practice Address - Country:US
Practice Address - Phone:540-915-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer