Provider Demographics
NPI:1427138585
Name:MOORE, ELIZABETH KAYE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KAYE
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 1:766 OLD TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:FONDA
Mailing Address - State:NY
Mailing Address - Zip Code:12068-5302
Mailing Address - Country:US
Mailing Address - Phone:518-368-6427
Mailing Address - Fax:
Practice Address - Street 1:7 TIMMERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452-1017
Practice Address - Country:US
Practice Address - Phone:518-568-5037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist