Basic Information
| Provider Information | |||||||||
| NPI: | 1669979290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 SOUTHBURN DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370753013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159441928 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 247 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370757320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155644984 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 11830102 | TN | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.