Healthcare Provider Details

I. General information

NPI: 1558426593
Provider Name (Legal Business Name): STACEY L S MOORE MOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/19/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2895 SE POWELL VALLEY RD
GRESHAM OR
97080-1492
US

IV. Provider business mailing address

12806 NE SAN RAFAEL ST
PORTLAND OR
97230-1826
US

V. Phone/Fax

Practice location:
  • Phone: 971-571-5319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC-009631
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1073412
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: