MEDICARE: MRS. NICOLE MARIE MOES MS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225XP0200X	Pediatric Occupational Therapist	OT11229	FL

General Provider Information

NPI Number	:	1649255597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE MARIE MOES MS OTRL

Provider Business Mailing Address
First Line	:	8613 BINGHAMTON AVE
Second Line	:
City	:	BOYNTON BCH
State	:	FL
Zip	:	33436
Country	:	US
Telephone Number	:	954-818-5172
Fax Number	:

Provider Business Practice Location Address
First Line	:	3066 JOG RD
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33467-2053
Country	:	US
Telephone Number	:	561-357-5883
Fax Number	:	561-357-5884

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2005
Last Update Date	:	07/08/2007

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