Basic Information
Provider Information | |||||||||
NPI: | 1518319276 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOORE AUTISM CENTER, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1044 SW 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MOORE | ||||||||
State: | OK | ||||||||
PostalCode: | 731602405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057356333 | ||||||||
FaxNumber: | 4057356629 | ||||||||
Practice Location | |||||||||
Address1: | 1044 SW 4TH ST | ||||||||
Address2: |   | ||||||||
City: | MOORE | ||||||||
State: | OK | ||||||||
PostalCode: | 731602405 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057356333 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2016 | ||||||||
LastUpdateDate: | 07/06/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARD | ||||||||
AuthorizedOfficialFirstName: | DUSTIN | ||||||||
AuthorizedOfficialMiddleName: | G | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4057356333 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC2200X | 1011 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.