Healthcare Provider Details

I. General information

NPI: 1871965467
Provider Name (Legal Business Name): NATHANAEL DAVID MOORE OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NATHANAEL D MOORE OTR/L

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 VIRGINIA ST
GREENSBORO NC
27401-1313
US

IV. Provider business mailing address

2219 GRIFFITH DR
ORANGEBURG SC
29118-4011
US

V. Phone/Fax

Practice location:
  • Phone: 336-275-0927
  • Fax: 336-275-4834
Mailing address:
  • Phone: 412-708-1153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number009313
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number5674
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code225XH1200X
TaxonomyHand Occupational Therapist
License Number9958
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number020010
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC014112
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: