Provider Demographics
NPI:1194436840
Name:MOORE, CODI
Entity type:Individual
Prefix:
First Name:CODI
Middle Name:
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:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-0903
Mailing Address - Country:US
Mailing Address - Phone:864-630-7154
Mailing Address - Fax:
Practice Address - Street 1:424 HIGHWAY 101
Practice Address - Street 2:
Practice Address - City:LANDRUM
Practice Address - State:SC
Practice Address - Zip Code:29356-8980
Practice Address - Country:US
Practice Address - Phone:864-676-0028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst