Provider Demographics
NPI:1447021423
Name:MOORE, MOLLY ANN (LMT)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ROWAN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:500 RALEIGH CIR APT 5317
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8442
Mailing Address - Country:US
Mailing Address - Phone:854-219-2819
Mailing Address - Fax:
Practice Address - Street 1:900 BOWMAN RD STE 106
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3218
Practice Address - Country:US
Practice Address - Phone:843-883-2994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11461225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist