Provider Demographics
NPI:1073278404
Name:MOORE, SCOTT A (BCBA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 HOLLY PL
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1237
Mailing Address - Country:US
Mailing Address - Phone:618-315-4533
Mailing Address - Fax:
Practice Address - Street 1:502 HOLLY PL
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1237
Practice Address - Country:US
Practice Address - Phone:618-315-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-21-53681103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst