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General NPI Number Information
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NPI Number | 1174699011
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Entity Type | Individual
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Provider Name | CANDICE M. MOORE OTR L
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Gender | Female
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Dates
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Enumeration Date | 11/24/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4500 INTERSTATE 55 NORTH SUITE 291, HIGHLAND VILLAGE
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City | JACKSON
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State | MS
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Zip | 39211
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Country | US
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Telephone | 601-362-0859
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Fax | 601-362-0870
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Provider Business Mailing Address
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Address Line | 766 CLEARMONT DR
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City | PEARL
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State | MS
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Zip | 39208-6261
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | OT1713
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License Number State | MS
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