Provider Demographics
NPI:1114236619
Name:MOORE, CHARLES RAY (EDD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:DR
Other - First Name:CHARLIE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:EDD
Mailing Address - Street 1:10000 N CENTRAL EXPY
Mailing Address - Street 2:STE 400, #467
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4177
Mailing Address - Country:US
Mailing Address - Phone:214-763-9905
Mailing Address - Fax:
Practice Address - Street 1:10000 N CENTRAL EXPY
Practice Address - Street 2:STE 400, #467
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4177
Practice Address - Country:US
Practice Address - Phone:214-763-9905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling