Provider Demographics
NPI:1598832768
Name:MOORE, CRAIG L (PHD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 PINE TREE RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-4104
Mailing Address - Country:US
Mailing Address - Phone:903-759-1145
Mailing Address - Fax:903-759-1170
Practice Address - Street 1:206 PINE TREE RD.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-4104
Practice Address - Country:US
Practice Address - Phone:903-759-1145
Practice Address - Fax:903-759-1170
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30640103T00000X
TX216424103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00FJ95OtherBCBS
TX00FJ95Medicare ID - Type UnspecifiedPROVIDER ID