Provider Demographics
NPI:1295355741
Name:MOODIE, THOMAS JAMES (OTR)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:MOODIE
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 PANORAMA CT APT 313
Mailing Address - Street 2:
Mailing Address - City:RICHLAND CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53581-9217
Mailing Address - Country:US
Mailing Address - Phone:608-335-9733
Mailing Address - Fax:
Practice Address - Street 1:400 WATER AVE
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634-9054
Practice Address - Country:US
Practice Address - Phone:608-489-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6766-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6766-26OtherWISCONSIN DSPS OCCUPATIONAL THERAPY LICENSE