Provider Demographics
NPI:1639816234
Name:MOORE, ABBIE JEAN (COTA)
Entity type:Individual
Prefix:
First Name:ABBIE
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N 75TH AVE UNIT 2002
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-5029
Mailing Address - Country:US
Mailing Address - Phone:715-401-1130
Mailing Address - Fax:
Practice Address - Street 1:28100 TORCH PKWY
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-4026
Practice Address - Country:US
Practice Address - Phone:630-413-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTA-047064224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant