Provider Demographics
NPI:1568999266
Name:MORA, MADELINE
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:
Last Name:MORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:1424 SHAKESPEARE AVE
Mailing Address - Street 2:APT# 2FL
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452
Mailing Address - Country:US
Mailing Address - Phone:347-262-0850
Mailing Address - Fax:
Practice Address - Street 1:1424 SHAKESPEARE AVE
Practice Address - Street 2:APT# 2FL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452
Practice Address - Country:US
Practice Address - Phone:347-262-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009301224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant