Provider Demographics
NPI:1376156943
Name:MOORE, SAMUEL THOMAS (MED)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9943 E ALABAMA CIR APT 1426
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80247-6361
Mailing Address - Country:US
Mailing Address - Phone:918-949-8245
Mailing Address - Fax:
Practice Address - Street 1:8931 HURON ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80260-6806
Practice Address - Country:US
Practice Address - Phone:303-853-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0016398101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional