Provider Demographics
NPI:1326280256
Name:MOORE, ANISSA NICOLE (MED, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:ANISSA
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9822 COCHEM PATH
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4615
Mailing Address - Country:US
Mailing Address - Phone:210-823-4780
Mailing Address - Fax:
Practice Address - Street 1:9822 COCHEM PATH
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4615
Practice Address - Country:US
Practice Address - Phone:210-823-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-07-3621103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst