Provider Demographics
NPI:1134384191
Name:MOODY, CORINNE L (OT)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:L
Last Name:MOODY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:CORRINE
Other - Middle Name:L
Other - Last Name:KOBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:691 MURPHY RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4346
Mailing Address - Country:US
Mailing Address - Phone:541-789-5252
Mailing Address - Fax:541-789-5269
Practice Address - Street 1:100 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6041
Practice Address - Country:US
Practice Address - Phone:541-789-5526
Practice Address - Fax:541-789-5203
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR591057225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics