Provider Demographics
NPI:1780397901
Name:MOSS, THOMAS RYAN (LOTR)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:RYAN
Last Name:MOSS
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 SWEET BAY CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-6726
Mailing Address - Country:US
Mailing Address - Phone:318-422-0486
Mailing Address - Fax:
Practice Address - Street 1:1041 CHINABERRY DR STE 100
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2466
Practice Address - Country:US
Practice Address - Phone:318-746-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-03
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123285225X00000X
LA333138225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist