Provider Demographics
NPI:1518453521
Name:MOORE PSYCHOLOGICAL SERVICES, PLLC
Entity Type:Organization
Organization Name:MOORE PSYCHOLOGICAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARLEN
Authorized Official - Middle Name:BROOK
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:575-760-1535
Mailing Address - Street 1:609 PROVIDENCE CIR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-1083
Mailing Address - Country:US
Mailing Address - Phone:575-760-1535
Mailing Address - Fax:800-561-2091
Practice Address - Street 1:1908 WEST 21ST STREET
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-760-1535
Practice Address - Fax:800-561-2091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY1511103T00000X
NM104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty