Provider Demographics
NPI:1205974110
Name:MOORE, PEGGY KAY (OT)
Entity type:Individual
Prefix:
First Name:PEGGY
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:KAY
Other - Last Name:DISTAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OT
Mailing Address - Street 1:2906 S 20TH ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3732
Mailing Address - Country:US
Mailing Address - Phone:414-385-6265
Mailing Address - Fax:414-383-5597
Practice Address - Street 1:2906 S 20TH ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3732
Practice Address - Country:US
Practice Address - Phone:414-385-6265
Practice Address - Fax:414-383-5597
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3492225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41042300Medicaid