Provider Demographics
NPI:1558872341
Name:MOORE, STACEY BRIGHAM
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:BRIGHAM
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4321 NW STATE ROAD 270
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-2303
Mailing Address - Country:US
Mailing Address - Phone:850-567-2095
Mailing Address - Fax:
Practice Address - Street 1:4321 NW STATE ROAD 270
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-2303
Practice Address - Country:US
Practice Address - Phone:850-567-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
DC251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services