Provider Demographics
NPI:1174015077
Name:MOORE, CONNOR IAN
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:IAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BROOKSEDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-3394
Mailing Address - Country:US
Mailing Address - Phone:614-882-9338
Mailing Address - Fax:
Practice Address - Street 1:4111 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43207-4988
Practice Address - Country:US
Practice Address - Phone:614-491-4921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker