Healthcare Provider Details

I. General information

NPI: 1013842384
Provider Name (Legal Business Name): MADILYN LEE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5211 MARSH RD
OKEMOS MI
48864-1106
US

IV. Provider business mailing address

2827 HOLLYWOOD ST
LANSING MI
48906-2834
US

V. Phone/Fax

Practice location:
  • Phone: 517-319-1440
  • Fax:
Mailing address:
  • Phone: 517-803-0018
  • Fax: 517-803-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number5202010312
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: