Provider Demographics
NPI:1871965467
Name:MOORE, NATHANAEL DAVID (OTR/L)
Entity type:Individual
Prefix:MR
First Name:NATHANAEL
Middle Name:DAVID
Last Name:MOORE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 GRIFFITH DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-4011
Mailing Address - Country:US
Mailing Address - Phone:412-708-1153
Mailing Address - Fax:
Practice Address - Street 1:1211 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1313
Practice Address - Country:US
Practice Address - Phone:336-275-0927
Practice Address - Fax:336-275-4834
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020010225X00000X
OH009313225X00000X
PAOC014112225X00000X
SC5674225XH1200X
NC9958225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist