Healthcare Provider Details

I. General information

NPI: 1922382266
Provider Name (Legal Business Name): MARGARET M MOORE BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARGARET M DICKSON BCBA

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3361 36TH ST SE
KENTWOOD MI
49512-2809
US

IV. Provider business mailing address

12650 HAMILTON CROSSING BLVD
CARMEL IN
46032-5400
US

V. Phone/Fax

Practice location:
  • Phone: 616-726-1952
  • Fax:
Mailing address:
  • Phone: 317-249-2242
  • Fax: 317-663-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-11-8077
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: