Healthcare Provider Details

I. General information

NPI: 1376917260
Provider Name (Legal Business Name): SUZANNE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 LAUREL ST
COLUMBIA SC
29201-2500
US

IV. Provider business mailing address

1400 LAUREL ST
COLUMBIA SC
29201-2500
US

V. Phone/Fax

Practice location:
  • Phone: 301-821-5357
  • Fax:
Mailing address:
  • Phone: 301-821-5357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-21462
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: