Healthcare Provider Details

I. General information

NPI: 1275441933
Provider Name (Legal Business Name): MADELINE ELIZABETH MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 EAGLE WAY
ASHLAND OH
44805-8924
US

IV. Provider business mailing address

238 SAMARITAN AVE
ASHLAND OH
44805-3822
US

V. Phone/Fax

Practice location:
  • Phone: 419-903-0202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2608022
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: