Basic Information
| Provider Information | |||||||||
| NPI: | 1235689993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | RANDA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.ED., BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3016 S MINNESOTA AVE | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648042848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606148710 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2620 FORUM BLVD STE E | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652035454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5735148735 | ||||||||
| FaxNumber: | 5737222133 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2016 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 730081389 | 05 | MO | MEDICAID |