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NPI Code Detail

MEDICARE: MELISSA MOOSE OT

MEDICARE: MELISSA MOOSE OT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist4791NC

General Provider Information

NPI Number : 1205950490
Entity Type Code : Individual
Provider Name (Legal Business Name) : MELISSA MOOSE OT
Provider Business Mailing Address
First Line : 174 SCOTT RD
Second Line :
City : LEWISVILLE
State : NC
Zip : 27023-8168
Country : US
Telephone Number : 336-734-1734
Fax Number : 336-723-7828
Provider Business Practice Location Address
First Line : 2500 POLO RIDGE CT
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27106-3950
Country : US
Telephone Number : 336-734-1734
Fax Number : 336-723-7828
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/16/2007
Last Update Date : 07/08/2007

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