Healthcare Provider Details

I. General information

NPI: 1699692061
Provider Name (Legal Business Name): TREVENA B MOORE, MD & ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 ESTATE DIAMOND STE 4
CHRISTIANSTED VI
00820-5233
US

IV. Provider business mailing address

10608 S MILLSTONE DR
OLATHE KS
66061-9106
US

V. Phone/Fax

Practice location:
  • Phone: 617-306-2065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: TREVENA MOORE
Title or Position: PRESIDENT
Credential: MD
Phone: 617-306-2065