MEDICARE: BEVERLY MOORE

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
1	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1831660612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY MOORE

Provider Business Mailing Address
First Line	:	953 E 128TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2583
Country	:	US
Telephone Number	:	216-785-4179
Fax Number	:

Provider Business Practice Location Address
First Line	:	953 E 128TH ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44108-2583
Country	:	US
Telephone Number	:	216-785-4179
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2018
Last Update Date	:	12/05/2018

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Directions to “ BEVERLY MOORE ” Practice Location

Language	Start Address	Practice Location

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