Provider Demographics
NPI:1578821310
Name:PRENDERGAST-MOORE, TAYLOR ELLEN (OTR/L)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:ELLEN
Last Name:PRENDERGAST-MOORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:ELLEN
Other - Last Name:PRENDERGAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 1772
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03821-1772
Mailing Address - Country:US
Mailing Address - Phone:207-286-6832
Mailing Address - Fax:
Practice Address - Street 1:15 CONCORD ROAD
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:NH
Practice Address - Zip Code:03861
Practice Address - Country:US
Practice Address - Phone:603-609-5685
Practice Address - Fax:866-702-2502
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2020225XP0200X
MA10576225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist