Provider Demographics
NPI:1205419207
Name:MOORE, CARLTON J
Entity Type:Individual
Prefix:
First Name:CARLTON
Middle Name:J
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 1:828 S CARAWAY RD APT 216B
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4492
Mailing Address - Country:US
Mailing Address - Phone:513-901-8921
Mailing Address - Fax:
Practice Address - Street 1:828 S CARAWAY RD APT 216B
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4492
Practice Address - Country:US
Practice Address - Phone:513-901-8921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR267954789657101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2367856Medicaid