Provider Demographics
NPI:1215586276
Name:MOORE, MADISON SARA (BSW)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:SARA
Last Name:MOORE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3058 N RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-9251
Mailing Address - Country:US
Mailing Address - Phone:252-814-3512
Mailing Address - Fax:
Practice Address - Street 1:925 CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-689-6645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician