Provider Demographics
NPI:1730526971
Name:MOORE, SUSAN JOSEPHINE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOSEPHINE
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 1:302 GLENWOOD DR
Mailing Address - Street 2:201
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-3318
Mailing Address - Country:US
Mailing Address - Phone:630-453-2970
Mailing Address - Fax:
Practice Address - Street 1:302 GLENWOOD DR
Practice Address - Street 2:201
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-3318
Practice Address - Country:US
Practice Address - Phone:630-453-2970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist