Provider Demographics
NPI:1366578528
Name:MOSELY, LADANE JERNELL (MS OTRL)
Entity type:Individual
Prefix:MS
First Name:LADANE
Middle Name:JERNELL
Last Name:MOSELY
Suffix:
Gender:F
Credentials:MS OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505 HIGHGATE DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4715
Mailing Address - Country:US
Mailing Address - Phone:443-520-2273
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE
Practice Address - Street 2:SUITE 200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7085
Practice Address - Country:US
Practice Address - Phone:800-684-8049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05398225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist