Provider Demographics
NPI:1003971615
Name:MOORE, DIANNE LOUISE (OTR)
Entity type:Individual
Prefix:
First Name:DIANNE
Middle Name:LOUISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4994 NAUTILUS RD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293-7732
Mailing Address - Country:US
Mailing Address - Phone:941-492-2092
Mailing Address - Fax:
Practice Address - Street 1:256 NOKOMIS AVE S STE 2
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285-2357
Practice Address - Country:US
Practice Address - Phone:941-484-1939
Practice Address - Fax:941-484-7804
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3289225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106625Medicare Oscar/Certification