Provider Demographics
NPI:1417496027
Name:MOORE, ANGELA (BS)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:STARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS
Mailing Address - Street 1:905 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-2848
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 S 30TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-2848
Practice Address - Country:US
Practice Address - Phone:918-933-3964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health