Provider Demographics
NPI:1215794524
Name:MOORE, KATHERINE ROSE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:ROSE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 S WILLIAMSON BLVD APT 5-308
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6549
Mailing Address - Country:US
Mailing Address - Phone:609-774-5277
Mailing Address - Fax:
Practice Address - Street 1:1525 HERBERT ST STE 103
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6107
Practice Address - Country:US
Practice Address - Phone:386-756-0424
Practice Address - Fax:386-756-0425
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL41394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist