Provider Demographics
NPI:1710641642
Name:MOORE, TIMIKA N (QMHS 3YR)
Entity Type:Individual
Prefix:
First Name:TIMIKA
Middle Name:N
Last Name:MOORE
Suffix:
Gender:F
Credentials:QMHS 3YR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E DUBLIN GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43085-3192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:WEST CARROLLTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2135
Practice Address - Country:US
Practice Address - Phone:937-247-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-27
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid