Provider Demographics
NPI:1174699011
Name:MOORE, CANDICE M (OTR L)
Entity type:Individual
Prefix:
First Name:CANDICE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:766 CLEARMONT DR
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-6261
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 INTERSTATE 55 NORTH
Practice Address - Street 2:SUITE 291, HIGHLAND VILLAGE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211
Practice Address - Country:US
Practice Address - Phone:601-362-0859
Practice Address - Fax:601-362-0870
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1713225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05170357Medicaid