Provider Demographics
NPI:1750030730
Name:MOORE, JOHN-MARK MILLER (BCBA)
Entity type:Individual
Prefix:
First Name:JOHN-MARK
Middle Name:MILLER
Last Name:MOORE
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3661 HAWKS LANDING CIR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9654
Mailing Address - Country:US
Mailing Address - Phone:904-655-9223
Mailing Address - Fax:
Practice Address - Street 1:3661 HAWKS LANDING CIR
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-9654
Practice Address - Country:US
Practice Address - Phone:904-655-9223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019703100Medicaid