Healthcare Provider Details

I. General information

NPI: 1902881220
Provider Name (Legal Business Name): ROXANN MOORE OTR/MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROXANN MOORE OTR/MHS

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 S 3RD ST
TERRE HAUTE IN
47802-1920
US

IV. Provider business mailing address

3000 S STATE ROAD 135 STE 110
GREENWOOD IN
46143-9829
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-4036
  • Fax: 812-235-0420
Mailing address:
  • Phone: 317-535-4075
  • Fax: 317-535-4076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31001814A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: