Provider Demographics
NPI:1417016718
Name:MOORE, KATHY (OT)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 QUINEEVIEW LANE
Mailing Address - Street 2:
Mailing Address - City:OWINGS
Mailing Address - State:MD
Mailing Address - Zip Code:20736
Mailing Address - Country:US
Mailing Address - Phone:410-257-5211
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4022
Practice Address - Country:US
Practice Address - Phone:410-535-8180
Practice Address - Fax:410-535-8325
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD606MMedicare ID - Type UnspecifiedMEDICARE