Provider Demographics
NPI:1497554547
Name:MOORE, MEGAN
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
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 1:4961 N SANTA MONICA BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4125 N 124TH ST
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-1837
Practice Address - Country:US
Practice Address - Phone:414-763-2341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst