Provider Demographics
NPI:1871223313
Name:MOOTS, EMMA NOELLE-MARIE
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:NOELLE-MARIE
Last Name:MOOTS
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 1:1501 JONES DR APT 22
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1837
Mailing Address - Country:US
Mailing Address - Phone:989-859-6626
Mailing Address - Fax:
Practice Address - Street 1:2830 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5806
Practice Address - Country:US
Practice Address - Phone:734-412-4727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502008022225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5502008022OtherMICHIGAN LICENSING BOARD