Provider Demographics
NPI:1033501184
Name:MOORE, TIMOTHY GLEN (PEER SUPPORT SPECIAL)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PEER SUPPORT SPECIAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3317 FINLEY RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-8722
Mailing Address - Country:US
Mailing Address - Phone:817-360-5364
Mailing Address - Fax:
Practice Address - Street 1:3317 FINLEY RD
Practice Address - Street 2:SUITE 120
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-8722
Practice Address - Country:US
Practice Address - Phone:817-360-5364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist