Provider Demographics
NPI:1922804368
Name:MOORE, SHAWNA ASHLEY
Entity type:Individual
Prefix:MS
First Name:SHAWNA
Middle Name:ASHLEY
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 1:170 KEARSARGE RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CONWAY
Mailing Address - State:NH
Mailing Address - Zip Code:03860-5331
Mailing Address - Country:US
Mailing Address - Phone:800-789-3062
Mailing Address - Fax:
Practice Address - Street 1:170 KEARSARGE RD
Practice Address - Street 2:
Practice Address - City:NORTH CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03860-5331
Practice Address - Country:US
Practice Address - Phone:800-789-3062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician