Provider Demographics
NPI:1417212333
Name:MOORE, ANTWON DEMETRIUS
Entity Type:Individual
Prefix:
First Name:ANTWON
Middle Name:DEMETRIUS
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANTWON
Other - Middle Name:DEMETRIUS
Other - Last Name:BURKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:811 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-3216
Mailing Address - Country:US
Mailing Address - Phone:580-491-0699
Mailing Address - Fax:
Practice Address - Street 1:500 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-5700
Practice Address - Country:US
Practice Address - Phone:405-601-1716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKJ082366771101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional