Provider Demographics
NPI:1760252753
Name:MOORE, EMILY NICOLE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 LAKESIDE TRL
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-8420
Mailing Address - Country:US
Mailing Address - Phone:678-699-5605
Mailing Address - Fax:
Practice Address - Street 1:410 PEACHTREE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-7407
Practice Address - Country:US
Practice Address - Phone:404-785-8922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-23-70249103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst