Provider Demographics
NPI:1902356637
Name:MOORE, ANGELA (RBT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 CIVIC CIR
Mailing Address - Street 2:STE. 210
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3424
Mailing Address - Country:US
Mailing Address - Phone:972-219-1200
Mailing Address - Fax:972-317-4422
Practice Address - Street 1:190 CIVIC CIR
Practice Address - Street 2:STE. 210
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3424
Practice Address - Country:US
Practice Address - Phone:972-219-1200
Practice Address - Fax:972-317-4422
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-16-12955106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXRBT-16-12955OtherREGISTERED BEHAVIOR TECHNICIAN