Provider Demographics
NPI:1205181260
Name:MOORE, MCKENZIE ANN (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RATT MILL HILL RD
Mailing Address - Street 2:
Mailing Address - City:READFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04355-3143
Mailing Address - Country:US
Mailing Address - Phone:352-322-1757
Mailing Address - Fax:
Practice Address - Street 1:15 ENTERPRISE DR STE 100
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-7998
Practice Address - Country:US
Practice Address - Phone:207-621-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT2716225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist