Healthcare Provider Details

I. General information

NPI: 1528933298
Provider Name (Legal Business Name): LEXIE ROSE MOORE OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2025
Last Update Date: 10/10/2025
Certification Date: 10/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2869 N LINCOLN AVE
CHICAGO IL
60657-4201
US

IV. Provider business mailing address

976 SAINT ANDREWS CIR
GENEVA IL
60134-2997
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-9950
  • Fax:
Mailing address:
  • Phone: 630-360-4390
  • Fax: 630-360-4390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056.016656
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: