Provider Demographics
NPI:1295465995
Name:MOORE, MOLLIE ETTA
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:ETTA
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10177 STATION WAY
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-6863
Mailing Address - Country:US
Mailing Address - Phone:720-808-6382
Mailing Address - Fax:
Practice Address - Street 1:10177 STATION WAY
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6863
Practice Address - Country:US
Practice Address - Phone:720-808-6382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician