Provider Demographics
NPI:1649755281
Name:THE MOORE EXPERIENCE
Entity Type:Organization
Organization Name:THE MOORE EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUANESE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:770-609-7288
Mailing Address - Street 1:375 ROCKBRIDGE RD NW STE 172-350
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-8225
Mailing Address - Country:US
Mailing Address - Phone:678-522-2472
Mailing Address - Fax:470-777-2790
Practice Address - Street 1:4500 HUGH HOWELL RD STE 620D
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4720
Practice Address - Country:US
Practice Address - Phone:678-522-2472
Practice Address - Fax:470-777-2790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-29
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health