Provider Demographics
NPI:1619177938
Name:MOORE, LISA (OT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2827 JODORE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2741
Mailing Address - Country:US
Mailing Address - Phone:419-461-0710
Mailing Address - Fax:
Practice Address - Street 1:3949 SUNFOREST CT
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4473
Practice Address - Country:US
Practice Address - Phone:419-474-3399
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT5068225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2208864Medicaid
OH9336626OtherPHCS
OH000000217661OtherANTHEM
OH366706Medicare ID - Type Unspecified