Provider Demographics
NPI:1679302145
Name:MOORE, EMILEE LANE (OTD, OTR/L)
Entity type:Individual
Prefix:DR
First Name:EMILEE
Middle Name:LANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 N FRANCISCO AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1410
Mailing Address - Country:US
Mailing Address - Phone:308-440-6721
Mailing Address - Fax:
Practice Address - Street 1:3319 N ELSTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-5811
Practice Address - Country:US
Practice Address - Phone:312-312-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.016136225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist