Provider Demographics
NPI:1639674823
Name:MOORE, DUSTIN (LSAA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2105
Mailing Address - Country:US
Mailing Address - Phone:505-564-3733
Mailing Address - Fax:
Practice Address - Street 1:511 E 20TH ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2105
Practice Address - Country:US
Practice Address - Phone:505-564-3733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCSA0195451101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)