Healthcare Provider Details

I. General information

NPI: 1710452057
Provider Name (Legal Business Name): SHERMAN CORNELL MOORE SR. CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax:
Mailing address:
  • Phone: 513-834-7063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.150745
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: