Provider Demographics
NPI:1578993101
Name:MOORE, COREY (MA, B,CBA)
Entity Type:Individual
Prefix:MRS
First Name:COREY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, B,CBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 SOUTH 6TH STREET ROAD
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5520 SOUTH 6TH STREET ROAD
Practice Address - Street 2:SUITE 1700
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703
Practice Address - Country:US
Practice Address - Phone:217-585-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst