Provider Demographics
NPI:1497070965
Name:MOORE, MARY MARGARET (CDP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:MOORE
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1845
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1845
Mailing Address - Country:US
Mailing Address - Phone:360-397-8488
Mailing Address - Fax:360-397-8494
Practice Address - Street 1:1601 E FOURTH PLAIN BLVD
Practice Address - Street 2:BLDG 17, STE 222
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-3753
Practice Address - Country:US
Practice Address - Phone:360-397-8488
Practice Address - Fax:360-397-8494
Is Sole Proprietor?:No
Enumeration Date:2010-03-28
Last Update Date:2010-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00002617101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)