Basic Information
| Provider Information | |||||||||
| NPI: | 1578090122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154251004 | ||||||||
| FaxNumber: | 3154224855 | ||||||||
| Practice Location | |||||||||
| Address1: | 1045 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132032730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154251004 | ||||||||
| FaxNumber: | 3154224855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 222Q00000X | 021340-1 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | 222Q00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 021340-1 | 01 | NY | REGISTERED OCCUPATIONAL THERAPIST | OTHER |