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NPI Code Detail

MEDICARE: SPECTRUM TRANSFORMATION GROUP, LLC

MEDICARE: SPECTRUM TRANSFORMATION GROUP, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst
2103TC2200XClinical Child & Adolescent Psychologist
31041C0700XClinical Social Worker
4103TB0200XCognitive & Behavioral Psychologist

General Provider Information

NPI Number : 1174855985
Entity Type Code : Organization
Provider Name (Legal Business Name) : SPECTRUM TRANSFORMATION GROUP, LLC
Provider Business Mailing Address
First Line : 221 STONEBRIDGE PLAZA AVE STE C
Second Line :
City : NORTH CHESTERFIELD
State : VA
Zip : 23225-6972
Country : US
Telephone Number : 804-378-6141
Fax Number :
Provider Business Practice Location Address
First Line : 221 STONEBRIDGE PLAZA AVE STE C
Second Line :
City : NORTH CHESTERFIELD
State : VA
Zip : 23225-6972
Country : US
Telephone Number : 804-378-6141
Fax Number :
Authorized Official
Title or Position : CHIEF EXECUTIVE OFFICER
Name : MR. CEDRIC MOORE JR.
Credential : MBA
Telephone Number : 804-317-4307
Provider Enumeration Date : 02/03/2010
Last Update Date : 11/17/2020

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