Provider Demographics
NPI:1295079077
Name:MOORE, AMANDA LILLIAN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LILLIAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 LEXINGTON ROAD
Mailing Address - Street 2:SUITE G
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-7924
Mailing Address - Country:US
Mailing Address - Phone:859-333-8147
Mailing Address - Fax:877-665-7294
Practice Address - Street 1:2150 LEXINGTON RD
Practice Address - Street 2:STE G
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-7924
Practice Address - Country:US
Practice Address - Phone:859-333-8147
Practice Address - Fax:877-665-7294
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR5437225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist