Provider Demographics
NPI:1114352333
Name:MOORE, MARLESA K (DPT)
Entity type:Individual
Prefix:MS
First Name:MARLESA
Middle Name:K
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 S RESERVE ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4755
Mailing Address - Country:US
Mailing Address - Phone:406-549-2006
Mailing Address - Fax:406-549-6574
Practice Address - Street 1:1519 S RESERVE ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4755
Practice Address - Country:US
Practice Address - Phone:406-549-2006
Practice Address - Fax:406-549-6574
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPTP-PT-LIC-5949225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTG8923345Medicare UPIN