Provider Demographics
NPI:1477030245
Name:MOORE, BRANDON EUGENE
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:EUGENE
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12303 CYRUS WAY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275
Mailing Address - Country:US
Mailing Address - Phone:425-931-5131
Mailing Address - Fax:
Practice Address - Street 1:12303 CYRUS WAY
Practice Address - Street 2:SUITE 107
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275
Practice Address - Country:US
Practice Address - Phone:425-931-5131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical