Provider Demographics
NPI:1376031666
Name:MOORE, TRAVIS (LPC)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 MONTEGO CT
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-7209
Mailing Address - Country:US
Mailing Address - Phone:214-677-6307
Mailing Address - Fax:
Practice Address - Street 1:1350 N BUCKNER BLVD STE 220
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3566
Practice Address - Country:US
Practice Address - Phone:972-602-5023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74796101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional