Provider Demographics
NPI:1407393846
Name:MOORE, MICHAEL CHARLES (CATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MOORE
Suffix:
Gender:M
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 W 77TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90047
Mailing Address - Country:US
Mailing Address - Phone:323-758-6104
Mailing Address - Fax:
Practice Address - Street 1:2123 W 77TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-2312
Practice Address - Country:US
Practice Address - Phone:323-758-6104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM1310071045101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)