MEDICARE: CRISTAL S MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1326521394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTAL S MOORE

Provider Business Mailing Address
First Line	:	514 W 5TH ST
Second Line	:
City	:	ROCHESTER
State	:	IN
Zip	:	46975-1224
Country	:	US
Telephone Number	:	574-223-3819
Fax Number	:

Provider Business Practice Location Address
First Line	:	514 W 5TH ST
Second Line	:
City	:	ROCHESTER
State	:	IN
Zip	:	46975-1224
Country	:	US
Telephone Number	:	574-223-3819
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2018
Last Update Date	:	09/14/2018

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Directions to “ CRISTAL S MOORE ” Practice Location

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