Provider Demographics
NPI:1124895552
Name:MOORE, STEPHANIE (MS, ADDC)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, ADDC
Other - Prefix:
Other - First Name:BRANDON
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, ADDC
Mailing Address - Street 1:3400 W 16TH ST STE P
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6871
Mailing Address - Country:US
Mailing Address - Phone:720-473-9650
Mailing Address - Fax:
Practice Address - Street 1:3400 W 16TH ST STE P
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6871
Practice Address - Country:US
Practice Address - Phone:970-978-4386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COADDC.0000354101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)