Provider Demographics
NPI:1427194877
Name:MOORE, JAMES EDDIE (CADC-III)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:EDDIE
Last Name:MOORE
Suffix:
Gender:M
Credentials:CADC-III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 W AUER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-3135
Mailing Address - Country:US
Mailing Address - Phone:414-444-3883
Mailing Address - Fax:
Practice Address - Street 1:2319 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-1919
Practice Address - Country:US
Practice Address - Phone:414-744-5370
Practice Address - Fax:414-744-9052
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2041101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39369400Medicaid