Healthcare Provider Details

I. General information

NPI: 1720159494
Provider Name (Legal Business Name): JOANNE MOIRA KEANE MOTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2526 VERANDA NW
ALBUQUERQUE NM
87107
US

IV. Provider business mailing address

2526 VERANDA NW
ALBUQUERQUE NM
87107
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-4096
  • Fax: 505-266-2422
Mailing address:
  • Phone: 505-550-4096
  • Fax: 505-266-2422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2118
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code225XH1300X
TaxonomyHuman Factors Occupational Therapist
License Number2118
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: