Provider Demographics
NPI:1144757444
Name:MOORE, STEPHANI (EDM, LBA, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANI
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:EDM, LBA, BCBA
Other - Prefix:
Other - First Name:STEPHANI
Other - Middle Name:
Other - Last Name:KMETOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 88083
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98138-2083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3680 S CEDAR ST STE A
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-5728
Practice Address - Country:US
Practice Address - Phone:253-289-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABA61167965103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111524501Medicaid