Provider Demographics
NPI:1699419556
Name:MOORE, LEEANN
Entity type:Individual
Prefix:MS
First Name:LEEANN
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 1:210 4TH ST
Mailing Address - Street 2:
Mailing Address - City:W.KEANSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07734-2918
Mailing Address - Country:US
Mailing Address - Phone:732-768-7227
Mailing Address - Fax:
Practice Address - Street 1:210 4TH ST
Practice Address - Street 2:
Practice Address - City:HAZLET TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07734-2918
Practice Address - Country:US
Practice Address - Phone:732-768-7227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
385H00000X, 320600000X
NJ320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities