Provider Demographics
NPI:1942701503
Name:MOORE, MICHAELA RAE
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:RAE
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 1:410 TEACO RD
Mailing Address - Street 2:
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3239
Mailing Address - Country:US
Mailing Address - Phone:870-565-9776
Mailing Address - Fax:
Practice Address - Street 1:410 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3239
Practice Address - Country:US
Practice Address - Phone:870-565-9776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0-23-14253106E00000X
106S00000X
LARBT-17-29629106S00000X
MO2024045907103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician