Healthcare Provider Details

I. General information

NPI: 1114962982
Provider Name (Legal Business Name): LAURA MOERMAN OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 05/10/2025
Certification Date: 05/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 RILEY LN
ST AUGUSTINE FL
32095-6832
US

IV. Provider business mailing address

820 RILEY LN
ST AUGUSTINE FL
32095-6832
US

V. Phone/Fax

Practice location:
  • Phone: 904-575-1750
  • Fax:
Mailing address:
  • Phone: 904-575-1750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3038-026
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT17721
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: