Provider Demographics
NPI:1922788520
Name:MOORE, STEVIE NICOLE (PEER SUPPORT)
Entity Type:Individual
Prefix:
First Name:STEVIE
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 GRIERSON PL
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2725
Mailing Address - Country:US
Mailing Address - Phone:937-250-2826
Mailing Address - Fax:
Practice Address - Street 1:4977 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3839
Practice Address - Country:US
Practice Address - Phone:937-387-6395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.004087175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist