Provider Demographics
NPI:1518565803
Name:MOORE, NATHANIEL A (LAC)
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HUBBART DAM RD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:MT
Mailing Address - Zip Code:59925-9708
Mailing Address - Country:US
Mailing Address - Phone:406-296-4272
Mailing Address - Fax:406-854-2835
Practice Address - Street 1:200 HUBBART DAM RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:MT
Practice Address - Zip Code:59925-9708
Practice Address - Country:US
Practice Address - Phone:406-296-4272
Practice Address - Fax:406-854-2835
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11780420-6006101YA0400X
MTBBH-LAC-LIC-30140101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)