Provider Demographics
NPI:1427606326
Name:MOORE, CARLY CATHERINE (BS)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:CATHERINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 BURNET RD APT 472
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756-2826
Mailing Address - Country:US
Mailing Address - Phone:404-909-6689
Mailing Address - Fax:
Practice Address - Street 1:1009 N GEORGETOWN ST
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-3289
Practice Address - Country:US
Practice Address - Phone:512-255-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX5052103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician