Healthcare Provider Details

I. General information

NPI: 1932289741
Provider Name (Legal Business Name): MARY E MOSKWA OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 06/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5099 E 81ST AVE
MERRILLVILLE IN
46410-5912
US

IV. Provider business mailing address

625 ENTERPRISE DR.
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 219-791-0494
  • Fax:
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31000189A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: