| Moore Autism Center, P.c. | |
|
1044 Sw 4th St Moore OK 73160-2405 | |
| (405) 735-6333 | |
| Not Available |
| Full Name | Moore Autism Center, P.c. |
|---|---|
| Speciality | Psychologist |
| Location | 1044 Sw 4th St, Moore, Oklahoma |
| Authorized Official Name and Position | Dustin G Ward (OWNER/DIRECTOR) |
| Authorized Official Contact | 4057356333 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Moore Autism Center, P.c. 1044 Sw 4th St Moore OK 73160-2405 Ph: (405) 735-6333 | Moore Autism Center, P.c. 1044 Sw 4th St Moore OK 73160-2405 Ph: (405) 735-6333 |
| NPI Number | 1518319276 |
|---|---|
| Provider Enumeration Date | 07/06/2016 |
| Last Update Date | 07/06/2016 |
| Medicare PECOS PAC ID | 2062841646 |
|---|---|
| Medicare Enrollment ID | O20200402000813 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518319276 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC2200X | Psychologist - Clinical Child & Adolescent | 1011 (Oklahoma) | Primary |
| Provider Name | Virginia Burk |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1629587118 PECOS PAC ID: 0648609149 Enrollment ID: I20200404000088 |
| Provider Name | Emily N Sullivan |
|---|---|
| Provider Type | Practitioner - Qualified Speech Language Pathologist |
| Provider Identifiers | NPI Number: 1265739502 PECOS PAC ID: 8426487927 Enrollment ID: I20200404000268 |
| Provider Name | Sonja Mangrum |
|---|---|
| Provider Type | Practitioner - Occupational Therapist In Private Practice |
| Provider Identifiers | NPI Number: 1194822916 PECOS PAC ID: 7618308552 Enrollment ID: I20200511000776 |
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