Provider Demographics
NPI:1164991717
Name:MOORE, MADELINE JACKSON (MS, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:JACKSON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4810 SETON DR
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4810 SETON DR
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3210
Practice Address - Country:US
Practice Address - Phone:410-358-8270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-13
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07531225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist