Provider Demographics
NPI:1538654215
Name:MOORE, AMANDA L (ALC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-0801
Mailing Address - Fax:419-694-0004
Practice Address - Street 1:4900 UNIVERSITY SQ STE 30
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35816-1829
Practice Address - Country:US
Practice Address - Phone:256-489-0170
Practice Address - Fax:256-686-0179
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health