Provider Demographics
NPI:1407211345
Name:MOORE, BRENDAN (BA)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WELLESLEY DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-1422
Mailing Address - Country:US
Mailing Address - Phone:808-365-3931
Mailing Address - Fax:
Practice Address - Street 1:12127 STATE HWY 14 N
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9461
Practice Address - Country:US
Practice Address - Phone:505-286-3678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-18
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YS0200X
NM2106225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool