Provider Demographics
NPI:1912413816
Name:MOFFETT, CASANYA T (LMT)
Entity type:Individual
Prefix:MS
First Name:CASANYA
Middle Name:T
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 SWIFT CURRENT DR
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:TX
Mailing Address - Zip Code:76036-6419
Mailing Address - Country:US
Mailing Address - Phone:817-371-2980
Mailing Address - Fax:
Practice Address - Street 1:208 E MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:TX
Practice Address - Zip Code:76036-2665
Practice Address - Country:US
Practice Address - Phone:682-231-1511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-15
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT128802225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist