Provider Demographics
NPI:1457132102
Name:MOORE, SUMMER HENRY (COTA/L)
Entity Type:Individual
Prefix:MRS
First Name:SUMMER
Middle Name:HENRY
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 COUNTY LINE ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:MS
Mailing Address - Zip Code:39365-3202
Mailing Address - Country:US
Mailing Address - Phone:601-616-4897
Mailing Address - Fax:
Practice Address - Street 1:101 KIRKLAND ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-3205
Practice Address - Country:US
Practice Address - Phone:601-774-8233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOTA-3948224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant