Provider Demographics
NPI:1679034037
Name:MOORE, CARLY JANE (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BLVD STE 3070
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:215 S HURSTBOURNE PKWY STE 213
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4937
Practice Address - Country:US
Practice Address - Phone:502-353-2074
Practice Address - Fax:317-520-8200
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY288824103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
1-23-68942OtherBCBA CERTIFICATE