Healthcare Provider Details

I. General information

NPI: 1003880717
Provider Name (Legal Business Name): TAMMARA J MOORE DPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SHORELINE HWY STE 210A
MILL VALLEY CA
94941-3645
US

IV. Provider business mailing address

136 UPLAND RD
KENTFIELD CA
94904-2738
US

V. Phone/Fax

Practice location:
  • Phone: 415-729-0441
  • Fax:
Mailing address:
  • Phone: 510-823-7154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15427
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number15427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: