Provider Demographics
NPI:1508121302
Name:MOORE, TIMOTHY ROBERT (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:MOORE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 S FARRELL DR
Mailing Address - Street 2:STE. C- 208
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7992
Mailing Address - Country:US
Mailing Address - Phone:760-325-4088
Mailing Address - Fax:760-779-9403
Practice Address - Street 1:490 S FARRELL DR
Practice Address - Street 2:STE. 202
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-7992
Practice Address - Country:US
Practice Address - Phone:760-325-4088
Practice Address - Fax:760-779-9403
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-08
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA179271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical