Provider Demographics
NPI:1306669346
Name:MOORE, ANNILYCE
Entity type:Individual
Prefix:
First Name:ANNILYCE
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 1:50 21ST AVE APT E2
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-1235
Mailing Address - Country:US
Mailing Address - Phone:720-276-3119
Mailing Address - Fax:
Practice Address - Street 1:7220 W JEFFERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80235-2015
Practice Address - Country:US
Practice Address - Phone:303-225-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician