Provider Demographics
NPI:1982143152
Name:MOORE, TRACY LEIGH (BACHELORS OF SCIENCE)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:LEIGH
Last Name:MOORE
Suffix:
Gender:F
Credentials:BACHELORS OF SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4191 COUNTY ROAD 450
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-7713
Mailing Address - Country:US
Mailing Address - Phone:573-718-1901
Mailing Address - Fax:573-686-1029
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:573-686-1029
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator