Provider Demographics
NPI:1144060096
Name:MOORE, NATASHA
Entity type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:GRETHEL
Mailing Address - State:KY
Mailing Address - Zip Code:41631-6321
Mailing Address - Country:US
Mailing Address - Phone:606-497-5507
Mailing Address - Fax:
Practice Address - Street 1:153 MAPLE ST
Practice Address - Street 2:
Practice Address - City:GRETHEL
Practice Address - State:KY
Practice Address - Zip Code:41631-6321
Practice Address - Country:US
Practice Address - Phone:606-497-5507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201199560222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty