Provider Demographics
NPI:1184130296
Name:MOORE, JANICE RENEE
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MONTEBELLO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-1366
Mailing Address - Country:US
Mailing Address - Phone:719-545-2746
Mailing Address - Fax:719-542-9638
Practice Address - Street 1:1304 CHINOOK LN
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81001-1851
Practice Address - Country:US
Practice Address - Phone:719-545-2746
Practice Address - Fax:719-584-0110
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
COACA.0007115101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician