Provider Demographics
NPI:1760960561
Name:MOORE, NATHAN ALLEN (RBT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:ALLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BUCKINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60404-0565
Mailing Address - Country:US
Mailing Address - Phone:815-630-1528
Mailing Address - Fax:
Practice Address - Street 1:510 BUCKINGHAM PL
Practice Address - Street 2:
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60404-0565
Practice Address - Country:US
Practice Address - Phone:815-630-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-18-60557106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician