Provider Demographics
NPI:1487045092
Name:MOORE, EVETTE RENEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:EVETTE
Middle Name:RENEE
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 1:1101 LA GRANDE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20903-1325
Mailing Address - Country:US
Mailing Address - Phone:301-445-4242
Mailing Address - Fax:
Practice Address - Street 1:1101 LA GRANDE RD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20903-1325
Practice Address - Country:US
Practice Address - Phone:301-445-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT130225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCOT130OtherOCCUPATIONAL THERAPY LICENSE NUMBER