Provider Demographics
NPI:1093101206
Name:MOORE, TERRENA
Entity Type:Individual
Prefix:
First Name:TERRENA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W WAVELAND AVE
Mailing Address - Street 2:APT. 405
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4188
Mailing Address - Country:US
Mailing Address - Phone:773-297-3735
Mailing Address - Fax:
Practice Address - Street 1:707 W WAVELAND AVE
Practice Address - Street 2:APT. 405
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4188
Practice Address - Country:US
Practice Address - Phone:773-297-3735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist