Provider Demographics
NPI:1538592456
Name:MOORE, KRISTEN MARY (PT)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MARY
Last Name:MOORE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7440 N SHADELAND AVE
Mailing Address - Street 2:130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2029
Mailing Address - Country:US
Mailing Address - Phone:317-577-7333
Mailing Address - Fax:317-577-7330
Practice Address - Street 1:7440 N SHADELAND AVE
Practice Address - Street 2:130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2029
Practice Address - Country:US
Practice Address - Phone:317-577-7333
Practice Address - Fax:317-577-7330
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN05006437A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN05006437AOtherPHYSICAL THERAPY STATE LICENSE