Provider Demographics
NPI:1629196068
Name:MOIST, PENNI MARIE (OTRL)
Entity type:Individual
Prefix:
First Name:PENNI
Middle Name:MARIE
Last Name:MOIST
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2013 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:PA
Mailing Address - Zip Code:18052-4809
Mailing Address - Country:US
Mailing Address - Phone:610-443-0022
Mailing Address - Fax:
Practice Address - Street 1:GRACEDALE AVE.
Practice Address - Street 2:
Practice Address - City:NAZARETH
Practice Address - State:PA
Practice Address - Zip Code:18064
Practice Address - Country:US
Practice Address - Phone:610-746-1906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC009570225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist