Provider Demographics
NPI:1932369121
Name:MOORE, DAVE JAMES (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:DAVE
Middle Name:JAMES
Last Name:MOORE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:MR
Other - First Name:DAVID
Other - Middle Name:JAMES
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3128 WILDFLOWER LN
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WI
Mailing Address - Zip Code:53037-8928
Mailing Address - Country:US
Mailing Address - Phone:262-510-7277
Mailing Address - Fax:
Practice Address - Street 1:807 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9767
Practice Address - Country:US
Practice Address - Phone:262-675-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4262-026225XE1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistErgonomics