Provider Demographics
NPI:1346858875
Name:MOORE, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
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 1:5800 29TH ST APT 631
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-8232
Mailing Address - Country:US
Mailing Address - Phone:615-579-4910
Mailing Address - Fax:
Practice Address - Street 1:7251 W 20TH ST UNIT B
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-4626
Practice Address - Country:US
Practice Address - Phone:615-579-4910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CO1-22-57776103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-20-127489OtherBACB REGISTRATION NUMBER