Provider Demographics
NPI:1164729463
Name:MOORE, LAURIE JOHNSON (OTR)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JOHNSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 TRACEWOOD CV
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-1546
Mailing Address - Country:US
Mailing Address - Phone:281-589-0789
Mailing Address - Fax:
Practice Address - Street 1:1815 ENCLAVE PKWY
Practice Address - Street 2:APT. 6307
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77077-3671
Practice Address - Country:US
Practice Address - Phone:281-920-0573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107672225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
993770OtherNATIONAL BOARD FOR CERTIFICATION IN OCCUPATIONAL THERAPY, INC.