Provider Demographics
NPI:1952035016
Name:MOORE, BAILEY A (COTA)
Entity Type:Individual
Prefix:MISS
First Name:BAILEY
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 HATMAKER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-4841
Mailing Address - Country:US
Mailing Address - Phone:423-494-4313
Mailing Address - Fax:
Practice Address - Street 1:101 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:TN
Practice Address - Zip Code:37716-3622
Practice Address - Country:US
Practice Address - Phone:865-457-9157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003677224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant