Provider Demographics
NPI:1417398652
Name:MOORE, JUDITH GOTHARD
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:GOTHARD
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 1:1413 INDIAN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-2007
Mailing Address - Country:US
Mailing Address - Phone:706-347-0655
Mailing Address - Fax:
Practice Address - Street 1:1413 INDIAN WOODS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-2007
Practice Address - Country:US
Practice Address - Phone:706-347-0655
Practice Address - Fax:706-453-0019
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator