Provider Demographics
NPI:1942805734
Name:MOORE, RODERICK (PA/ADMIN ASST)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA/ADMIN ASST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MEIGS AVE
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077-1129
Mailing Address - Country:US
Mailing Address - Phone:440-391-7248
Mailing Address - Fax:
Practice Address - Street 1:796 OAK ST
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-4335
Practice Address - Country:US
Practice Address - Phone:440-391-7248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)