Provider Demographics
NPI:1720197627
Name:MOSELEY, MIRANDA R (LOTR)
Entity Type:Individual
Prefix:MRS
First Name:MIRANDA
Middle Name:R
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:LOTR
Other - Prefix:MRS
Other - First Name:MIRANDA
Other - Middle Name:
Other - Last Name:AINSWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LOTR
Mailing Address - Street 1:1041 EDGEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2205 E 70TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-795-3388
Practice Address - Fax:318-795-3399
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ12338225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C869Medicare ID - Type UnspecifiedGROUP
LA4C620C869Medicare ID - Type Unspecified