Provider Demographics
NPI:1508591124
Name:MOORE, STEPHANIE MCHENRY (COTA/L)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MCHENRY
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DEVANT ST STE 703
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-2717
Mailing Address - Country:US
Mailing Address - Phone:770-847-6760
Mailing Address - Fax:
Practice Address - Street 1:101 DEVANT ST STE 703
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2717
Practice Address - Country:US
Practice Address - Phone:770-847-6760
Practice Address - Fax:404-393-6718
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA000570224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant