Provider Demographics
NPI:1356857650
Name:MOORE, FREDRICK ALLEN SR (LISW)
Entity Type:Individual
Prefix:MR
First Name:FREDRICK
Middle Name:ALLEN
Last Name:MOORE
Suffix:SR
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-2119
Mailing Address - Country:US
Mailing Address - Phone:707-424-1676
Mailing Address - Fax:
Practice Address - Street 1:101 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1809
Practice Address - Country:US
Practice Address - Phone:707-423-5174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMSW-162871041C0700X
OHI.20021071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical