Provider Demographics
NPI:1508043183
Name:MOORE, COLIN LANCE (BCBA)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:LANCE
Last Name:MOORE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 W WILSON ST APT E
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-1884
Mailing Address - Country:US
Mailing Address - Phone:812-814-0182
Mailing Address - Fax:423-296-4230
Practice Address - Street 1:1133 W WILSON ST APT E
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1884
Practice Address - Country:US
Practice Address - Phone:812-814-0182
Practice Address - Fax:812-814-0182
Is Sole Proprietor?:No
Enumeration Date:2008-01-26
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TM1800X, 103TP0814X
IL1-14-0724103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis