Healthcare Provider Details

I. General information

NPI: 1871754648
Provider Name (Legal Business Name): JULIE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 INTERSTATE DR
GRAYSON KY
41143-1768
US

IV. Provider business mailing address

PO BOX 790
ASHLAND KY
41105-0790
US

V. Phone/Fax

Practice location:
  • Phone: 606-474-5151
  • Fax: 606-475-3219
Mailing address:
  • Phone: 606-329-8588
  • Fax: 606-329-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: