Provider Demographics
NPI:1558183293
Name:MOORE, MARY AQUINAS
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:AQUINAS
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 1:110 OAK TER
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-2917
Mailing Address - Country:US
Mailing Address - Phone:818-664-8566
Mailing Address - Fax:
Practice Address - Street 1:110 OAK TER
Practice Address - Street 2:
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-2917
Practice Address - Country:US
Practice Address - Phone:818-664-8566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility