Provider Demographics
NPI:1437358975
Name:MOORE, CAROLYN NEOMA (CTRS)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:NEOMA
Last Name:MOORE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12007 S CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3344
Mailing Address - Country:US
Mailing Address - Phone:918-296-0355
Mailing Address - Fax:
Practice Address - Street 1:12007 S CEDAR AVE
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3344
Practice Address - Country:US
Practice Address - Phone:918-296-0355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-14
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist