Provider Demographics
NPI:1013343433
Name:MOORE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
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 1:13 TRAVERTINE LN TRLR 10
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-4125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 DURSTON RD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-2725
Practice Address - Country:US
Practice Address - Phone:406-582-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-17
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTOTP-OTA-LIC-2052224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant