Provider Demographics
NPI:1083038350
Name:MOORE, SANDRA (OTR)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:LEE
Other - Last Name:GOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:PSC 76 BOX 263
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09720-0003
Mailing Address - Country:US
Mailing Address - Phone:505-299-2643
Mailing Address - Fax:
Practice Address - Street 1:PSC 76 BOX 263
Practice Address - Street 2:65TH MED GROUP/SGH
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09720-0003
Practice Address - Country:US
Practice Address - Phone:505-299-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16006225X00000X
225XM0800X, 225XP0019X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics