Provider Demographics
NPI:1790550366
Name:MOORE, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10920 INLAND RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-8694
Mailing Address - Country:US
Mailing Address - Phone:681-264-0452
Mailing Address - Fax:
Practice Address - Street 1:400 MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:HARRISVILLE
Practice Address - State:WV
Practice Address - Zip Code:26362-1150
Practice Address - Country:US
Practice Address - Phone:304-643-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-23
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1099224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant