Provider Demographics
NPI:1386489847
Name:MOORE, THERESA MARY
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:MARY
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1032 SAN ANGELO DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-1880
Mailing Address - Country:US
Mailing Address - Phone:513-432-1456
Mailing Address - Fax:
Practice Address - Street 1:5248 COURSEVIEW DR # 2302
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-2302
Practice Address - Country:US
Practice Address - Phone:513-398-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33-018522225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist