Healthcare Provider Details

I. General information

NPI: 1184130296
Provider Name (Legal Business Name): JANICE RENEE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2017
Last Update Date: 01/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 CHINOOK LN
PUEBLO CO
81001-1851
US

IV. Provider business mailing address

41 MONTEBELLO RD STE 200
PUEBLO CO
81001-1366
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-2746
  • Fax: 719-584-0110
Mailing address:
  • Phone: 719-545-2746
  • Fax: 719-542-9638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACA.0007115
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: