1700098720 NPI number — ANDREA MARIE MOROGE M.ED., OTR/L

Table of content: (NPI 1942259403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700098720 NPI number — ANDREA MARIE MOROGE M.ED., OTR/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOROGE
Provider First Name:
ANDREA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.ED., OTR/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEBER
Provider Other First Name:
ANDREA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700098720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1940 S BONITO WAY STE 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642-5618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-287-9420
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
895 E STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83616-6003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-860-6229
Provider Business Practice Location Address Fax Number:
208-287-9426
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225XP0200X , with the licence number:  7776 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0200X , with the licence number: OT-640 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8084437 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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