Provider Demographics
NPI:1245517960
Name:MOORE, TIARA ROSE (OTR/L)
Entity type:Individual
Prefix:
First Name:TIARA
Middle Name:ROSE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 WOODPOINT AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-3556
Mailing Address - Country:US
Mailing Address - Phone:240-291-7805
Mailing Address - Fax:
Practice Address - Street 1:103 SHENANDOAH JUNCTION RD
Practice Address - Street 2:
Practice Address - City:SHENANDOAH JUNCTION
Practice Address - State:WV
Practice Address - Zip Code:25442-4757
Practice Address - Country:US
Practice Address - Phone:304-728-7250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1560225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics