Provider Demographics
NPI:1215281407
Name:MOORE, SAMANTHA DARLENE
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DARLENE
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 1:4334 BACK ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-5350
Mailing Address - Country:US
Mailing Address - Phone:580-565-0371
Mailing Address - Fax:
Practice Address - Street 1:4334 BACK ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:OK
Practice Address - Zip Code:73439-5350
Practice Address - Country:US
Practice Address - Phone:580-565-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-09
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid