Provider Demographics
NPI:1093708737
Name:MOORE, AUBREY LEE III (PHD)
Entity Type:Individual
Prefix:DR
First Name:AUBREY
Middle Name:LEE
Last Name:MOORE
Suffix:III
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:320 GARDENIA DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-8239
Mailing Address - Country:US
Mailing Address - Phone:706-284-1054
Mailing Address - Fax:706-729-0332
Practice Address - Street 1:3643 WALTON WAY EXT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4507
Practice Address - Country:US
Practice Address - Phone:706-729-9595
Practice Address - Fax:706-729-0332
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-29
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY002012103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS23446Medicare UPIN