Provider Demographics
NPI:1003623562
Name:MOORE, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 N WOLF ST
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:KS
Mailing Address - Zip Code:67025-8990
Mailing Address - Country:US
Mailing Address - Phone:620-727-5237
Mailing Address - Fax:
Practice Address - Street 1:212 N 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTHONY
Practice Address - State:KS
Practice Address - Zip Code:67003-2106
Practice Address - Country:US
Practice Address - Phone:620-491-0525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS18-01436224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant