Provider Demographics
NPI:1194097543
Name:MOORE SIMERLY, LEASA A (PTA)
Entity type:Individual
Prefix:MRS
First Name:LEASA
Middle Name:A
Last Name:MOORE SIMERLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22307 COUTY ROAD 243
Mailing Address - Street 2:
Mailing Address - City:UNION STAR
Mailing Address - State:MO
Mailing Address - Zip Code:64494
Mailing Address - Country:US
Mailing Address - Phone:816-593-2176
Mailing Address - Fax:
Practice Address - Street 1:1111 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:MO
Practice Address - Zip Code:64429-2005
Practice Address - Country:US
Practice Address - Phone:816-593-2176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant