Provider Demographics
NPI:1548750649
Name:MOORE, MARISA (OTR, CLT)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7081 SIENA PL APT 428
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-5364
Mailing Address - Country:US
Mailing Address - Phone:479-366-8530
Mailing Address - Fax:
Practice Address - Street 1:1101 OHIO DR STE 105
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5331
Practice Address - Country:US
Practice Address - Phone:972-599-9594
Practice Address - Fax:972-599-9364
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116262225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist