Healthcare Provider Details

I. General information

NPI: 1699497628
Provider Name (Legal Business Name): DELBERTA MOORE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2022
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 MORGANTOWN ST
KINGWOOD WV
26537-1095
US

IV. Provider business mailing address

419 MORGANTOWN ST
KINGWOOD WV
26537-1095
US

V. Phone/Fax

Practice location:
  • Phone: 304-329-3565
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA001570
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: