Provider Demographics
NPI:1376125252
Name:MOORE, MIRIAM (BA, RBT)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:BA, RBT
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BA, RBT
Mailing Address - Street 1:8626 OVERHILL DR
Mailing Address - Street 2:
Mailing Address - City:MANASSAS PARK
Mailing Address - State:VA
Mailing Address - Zip Code:20111-2313
Mailing Address - Country:US
Mailing Address - Phone:703-507-7276
Mailing Address - Fax:
Practice Address - Street 1:7771 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2879
Practice Address - Country:US
Practice Address - Phone:703-492-2686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA21157280106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician