Provider Demographics
NPI:1316240609
Name:MOORE, MAUREEN MARGARET (MT)
Entity type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:MARGARET
Last Name:MOORE
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 GREENVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-3322
Mailing Address - Country:US
Mailing Address - Phone:949-584-3507
Mailing Address - Fax:
Practice Address - Street 1:1525 GREENVIEW AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-3322
Practice Address - Country:US
Practice Address - Phone:949-584-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7529225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist