Provider Demographics
NPI:1235689993
Name:MOORE, RANDA A (MED, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:RANDA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-2848
Mailing Address - Country:US
Mailing Address - Phone:860-614-8710
Mailing Address - Fax:
Practice Address - Street 1:2620 FORUM BLVD STE E
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5454
Practice Address - Country:US
Practice Address - Phone:573-514-8735
Practice Address - Fax:573-722-2133
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730081389Medicaid