Healthcare Provider Details

I. General information

NPI: 1205419207
Provider Name (Legal Business Name): CARLTON J MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 S CARAWAY RD APT 216B
JONESBORO AR
72401-4492
US

IV. Provider business mailing address

828 S CARAWAY RD APT 216B
JONESBORO AR
72401-4492
US

V. Phone/Fax

Practice location:
  • Phone: 513-901-8921
  • Fax:
Mailing address:
  • Phone: 513-901-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number267954789657
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: