Provider Demographics
NPI:1275731630
Name:MOORE, LYNN MARIE (OTR)
Entity Type:Individual
Prefix:MRS
First Name:LYNN
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MS
Other - First Name:LYNN
Other - Middle Name:MARIE
Other - Last Name:CALLAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:48 DERBYSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:TULAROSA
Mailing Address - State:NM
Mailing Address - Zip Code:88352-9501
Mailing Address - Country:US
Mailing Address - Phone:505-585-4998
Mailing Address - Fax:505-585-4998
Practice Address - Street 1:3101 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-9713
Practice Address - Country:US
Practice Address - Phone:505-434-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist