Provider Demographics
NPI:1144846676
Name:MOORE, HEATHER (LMT)
Entity type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-1437
Mailing Address - Country:US
Mailing Address - Phone:864-621-7913
Mailing Address - Fax:
Practice Address - Street 1:20 MILL ST
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-1531
Practice Address - Country:US
Practice Address - Phone:864-621-7913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2020-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4509225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4509OtherMASSAGE LICENSE #