Provider Demographics
NPI:1689840332
Name:MOORE, TONY CURTIS (CADC,CCS)
Entity Type:Individual
Prefix:MR
First Name:TONY
Middle Name:CURTIS
Last Name:MOORE
Suffix:
Gender:M
Credentials:CADC,CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6723 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-4914
Mailing Address - Country:US
Mailing Address - Phone:262-605-8442
Mailing Address - Fax:262-605-8460
Practice Address - Street 1:6723 17TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-4914
Practice Address - Country:US
Practice Address - Phone:262-605-8442
Practice Address - Fax:262-605-8460
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10820-132101Y00000X
WI13313-135101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor