Provider Demographics
NPI:1033475850
Name:MOORE, CARL (CDP)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 S D ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-6813
Mailing Address - Country:US
Mailing Address - Phone:253-798-6572
Mailing Address - Fax:
Practice Address - Street 1:1901 MLK JR WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-4801
Practice Address - Country:US
Practice Address - Phone:206-322-7676
Practice Address - Fax:206-726-7585
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP 00006161101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)