Provider Demographics
NPI:1063930329
Name:MOSER, THEODORE NATHANIEL (LMT, CPMT II, CIMT)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:NATHANIEL
Last Name:MOSER
Suffix:
Gender:M
Credentials:LMT, CPMT II, CIMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:678 BERNARDSTON RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-1104
Mailing Address - Country:US
Mailing Address - Phone:413-522-0658
Mailing Address - Fax:
Practice Address - Street 1:187 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HADLEY
Practice Address - State:MA
Practice Address - Zip Code:01035-9521
Practice Address - Country:US
Practice Address - Phone:413-522-0658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9911-MT-MT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9911-MT-MTOtherDIVISION OF PROFESSIONAL LICENSURE, BOARD OF REGISTRATION OF MASSA