Provider Demographics
NPI:1902881220
Name:MOORE, ROXANN (OTR/MHS)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTR/MHS
Other - Prefix:
Other - First Name:ROXANN
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/MHS
Mailing Address - Street 1:3000 S STATE ROAD 135
Mailing Address - Street 2:STE 110
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9829
Mailing Address - Country:US
Mailing Address - Phone:317-535-4075
Mailing Address - Fax:317-535-4076
Practice Address - Street 1:1800 S 3RD ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-1920
Practice Address - Country:US
Practice Address - Phone:812-232-4036
Practice Address - Fax:812-235-0420
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31001814A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000316207OtherBLUE CROSS BLUE SHIELD