Provider Demographics
NPI:1912543497
Name:MOORE, STEPHANIE (MA, CADC, CTP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, CADC, CTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1646 305TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMA
Mailing Address - State:IA
Mailing Address - Zip Code:52339-9698
Mailing Address - Country:US
Mailing Address - Phone:641-484-9482
Mailing Address - Fax:641-484-9477
Practice Address - Street 1:1646 305TH ST
Practice Address - Street 2:
Practice Address - City:TAMA
Practice Address - State:IA
Practice Address - Zip Code:52339-9698
Practice Address - Country:US
Practice Address - Phone:641-484-9482
Practice Address - Fax:641-484-9477
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19016101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0074575Medicaid