Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | OTP-OTA-LIC-2052 | MT |
NPI | 1013343433 |
---|---|
Provider Name | Diane Moore |
First Address | Livingston, MT 59047-4125 |
Second Address | Bozeman, MT 59715-2725 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/09/2013 |
Last Update Date | 17/09/2013 |