Basic Information
| Provider Information | |||||||||
| NPI: | 1780257014 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | RENA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 COMPASS RD | ||||||||
| Address2: | |||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600268001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8777873430 | ||||||||
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| Practice Location | |||||||||
| Address1: | 695 MITZI ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494453232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317441641 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2021 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201009053 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 17992 | 05 | IL | MEDICAID |