Provider Demographics
NPI:1679199251
Name:MOORE, ANDREA NICOLE (MOT)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5284 S. COMMERCE DR.
Mailing Address - Street 2:SUITE C214
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:636-579-2994
Mailing Address - Fax:
Practice Address - Street 1:5284 S. COMMERCE DR.
Practice Address - Street 2:SUITE C214
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-871-5492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2024-02-28
Deactivation Date:2024-01-29
Deactivation Code:
Reactivation Date:2024-02-28
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT13803283-4201225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician