Provider Demographics
NPI:1518319276
Name:MOORE AUTISM CENTER, P.C.
Entity Type:Organization
Organization Name:MOORE AUTISM CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:405-735-6333
Mailing Address - Street 1:1044 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-2405
Mailing Address - Country:US
Mailing Address - Phone:405-735-6333
Mailing Address - Fax:405-735-6629
Practice Address - Street 1:1044 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2405
Practice Address - Country:US
Practice Address - Phone:405-735-6333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1011103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty