Provider Demographics
NPI:1508266230
Name:MOORE, AMBER (IECE)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 CHRISTOPHER GREENUP DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-0631
Mailing Address - Country:US
Mailing Address - Phone:270-663-1302
Mailing Address - Fax:270-663-1303
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:BLD E SUITE 104E
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-316-8885
Practice Address - Fax:270-663-1303
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY201129188222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist