Provider Demographics
NPI:1235853052
Name:MOORE, ROHAN T
Entity Type:Individual
Prefix:
First Name:ROHAN
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 W VIA PEDRO MIGUEL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85036
Mailing Address - Country:US
Mailing Address - Phone:910-797-9159
Mailing Address - Fax:
Practice Address - Street 1:5060 N 19TH AVE # 406-5
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-3210
Practice Address - Country:US
Practice Address - Phone:910-797-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician