Provider Demographics
NPI:1326747312
Name:MOORE, DWIGHT
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
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 1:9005 SNOWY OWL LN
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-9391
Mailing Address - Country:US
Mailing Address - Phone:360-223-4958
Mailing Address - Fax:
Practice Address - Street 1:9005 SNOWY OWL LN
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-9391
Practice Address - Country:US
Practice Address - Phone:360-223-4958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002436103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist