Healthcare Provider Details

I. General information

NPI: 1306669346
Provider Name (Legal Business Name): ANNILYCE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7220 W JEFFERSON AVE STE 100
LAKEWOOD CO
80235-2015
US

IV. Provider business mailing address

50 21ST AVE APT E2
LONGMONT CO
80501-1235
US

V. Phone/Fax

Practice location:
  • Phone: 303-225-7673
  • Fax:
Mailing address:
  • Phone: 720-276-3119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: