Provider Demographics
NPI:1588780472
Name:MOORE, MICHELE (COTA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DUBOISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17702-6713
Mailing Address - Country:US
Mailing Address - Phone:570-323-5688
Mailing Address - Fax:
Practice Address - Street 1:1201 RURAL AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1669
Practice Address - Country:US
Practice Address - Phone:570-323-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP002617L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant