Provider Demographics
NPI:1669898391
Name:MOORE, GLADYS
Entity type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 MORSON ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1559
Mailing Address - Country:US
Mailing Address - Phone:919-890-5569
Mailing Address - Fax:
Practice Address - Street 1:45 SOUTHERN VILLAGE DR
Practice Address - Street 2:
Practice Address - City:ROXBORO
Practice Address - State:NC
Practice Address - Zip Code:27573-2516
Practice Address - Country:US
Practice Address - Phone:919-890-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services