Provider Demographics
NPI:1376990556
Name:LARGE-MOORE, JANET (CHT)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:
Last Name:LARGE-MOORE
Suffix:
Gender:F
Credentials:CHT
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:JEAN
Other - Last Name:LARGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CHT
Mailing Address - Street 1:3125 43RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-2806
Mailing Address - Country:US
Mailing Address - Phone:253-224-4633
Mailing Address - Fax:
Practice Address - Street 1:4304 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-4033
Practice Address - Country:US
Practice Address - Phone:253-224-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHP10000249101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor