Provider Demographics
NPI:1194426536
Name:MOORE, STACY ALLYN
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:ALLYN
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6214 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 N OAK ST
Practice Address - Street 2:
Practice Address - City:HOISINGTON
Practice Address - State:KS
Practice Address - Zip Code:67544-1827
Practice Address - Country:US
Practice Address - Phone:785-639-4726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician