Provider Demographics
NPI:1376784157
Name:MOORE, JIM T (MS, NCC, LPC)
Entity Type:Individual
Prefix:MR
First Name:JIM
Middle Name:T
Last Name:MOORE
Suffix:
Gender:M
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-7626
Mailing Address - Fax:937-440-7702
Practice Address - Street 1:3130 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-7626
Practice Address - Fax:937-440-7702
Is Sole Proprietor?:No
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0005505101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health