Healthcare Provider Details

I. General information

NPI: 1962292029
Provider Name (Legal Business Name): MELISSA MOORE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2025
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16821 SE MCGILLIVRAY BLVD STE 104
VANCOUVER WA
98683-0401
US

IV. Provider business mailing address

16821 SE MCGILLIVRAY BLVD STE 104
VANCOUVER WA
98683-0401
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2048
  • Fax:
Mailing address:
  • Phone: 360-514-2048
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60159557
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT60159557
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: