Healthcare Provider Details

I. General information

NPI: 1801938436
Provider Name (Legal Business Name): GLENDA MARIE MOORE O. T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

371 SERENO RD
CORRALES NM
87048-8625
US

IV. Provider business mailing address

371 SERENO RD
CORRALES NM
87048-8625
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-7391
  • Fax: 505-352-7391
Mailing address:
  • Phone: 505-352-7391
  • Fax: 505-352-7391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1107
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: