Provider Demographics
NPI:1912377664
Name:MOORE, RONNY (PLADC)
Entity Type:Individual
Prefix:
First Name:RONNY
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PLADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 N 75TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-6861
Mailing Address - Country:US
Mailing Address - Phone:402-932-2248
Mailing Address - Fax:402-932-3557
Practice Address - Street 1:2808 N 75TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-6861
Practice Address - Country:US
Practice Address - Phone:402-932-2248
Practice Address - Fax:402-932-3557
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP432101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)