Provider Demographics
NPI:1134116544
Name:MOORE, JAMES MARVIN JR (EDD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MARVIN
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3188 MANSFIELD ST
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-7448
Mailing Address - Country:US
Mailing Address - Phone:352-409-7030
Mailing Address - Fax:
Practice Address - Street 1:3188 MANSFIELD ST
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-7448
Practice Address - Country:US
Practice Address - Phone:352-409-7030
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3671103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75793OtherBC/BS ID NUMER