Provider Demographics
NPI:1851027221
Name:MOORE, MADISON D (MOT, OTR/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:D
Last Name:MOORE
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 S 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-2628
Mailing Address - Country:US
Mailing Address - Phone:903-229-0600
Mailing Address - Fax:
Practice Address - Street 1:220 N 17TH ST # A
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-5029
Practice Address - Country:US
Practice Address - Phone:903-229-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122840225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist