Healthcare Provider Details

I. General information

NPI: 1376046318
Provider Name (Legal Business Name): AMBER MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 S LONG STAR WAY
ELGIN SC
29045-8575
US

IV. Provider business mailing address

1610 W 126TH ST
LOS ANGELES CA
90047-5226
US

V. Phone/Fax

Practice location:
  • Phone: 424-227-2024
  • Fax:
Mailing address:
  • Phone: 424-227-2024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-22-58694
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: