Provider Demographics
NPI:1710739784
Name:MOORE, RANDI LYNN (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:RANDI
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24951 E US HIGHWAY 50
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81006-2027
Mailing Address - Country:US
Mailing Address - Phone:719-542-0220
Mailing Address - Fax:
Practice Address - Street 1:24951 E US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81006-2027
Practice Address - Country:US
Practice Address - Phone:719-542-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOTA.0000019224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant