Healthcare Provider Details

I. General information

NPI: 1437818929
Provider Name (Legal Business Name): MORIAH NESSMITH OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2021
Last Update Date: 12/11/2021
Certification Date: 12/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

683 STATE AVE
DICKINSON ND
58601-4660
US

IV. Provider business mailing address

230 HUSSA ST
LINDEN NJ
07036-3022
US

V. Phone/Fax

Practice location:
  • Phone: 701-483-9400
  • Fax:
Mailing address:
  • Phone: 908-967-3556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR01023700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119009254
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1904
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: