Provider Demographics
NPI:1477547701
Name:MOORE, PAMELA MARIE (OTR)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:MARIE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6595 COLE RD
Mailing Address - Street 2:
Mailing Address - City:HAHIRA
Mailing Address - State:GA
Mailing Address - Zip Code:31632-3621
Mailing Address - Country:US
Mailing Address - Phone:229-563-0811
Mailing Address - Fax:229-794-8009
Practice Address - Street 1:6595 COLE RD
Practice Address - Street 2:
Practice Address - City:HAHIRA
Practice Address - State:GA
Practice Address - Zip Code:31632-3621
Practice Address - Country:US
Practice Address - Phone:229-563-0811
Practice Address - Fax:229-794-8009
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-01
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003205225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000885849EMedicaid