Provider Demographics
NPI:1730608894
Name:MOORE, MELISSA L (DPT)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:GOAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3226
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2121 S COLUMBIA AVE STE LL6
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3510
Practice Address - Country:US
Practice Address - Phone:918-895-7222
Practice Address - Fax:918-895-7223
Is Sole Proprietor?:No
Enumeration Date:2017-09-10
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5398225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200733400AMedicaid