Provider Demographics
NPI:1679643605
Name:MOORE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BOURNE
Mailing Address - State:MA
Mailing Address - Zip Code:02532-2227
Mailing Address - Country:US
Mailing Address - Phone:617-839-3429
Mailing Address - Fax:
Practice Address - Street 1:1 DOGWOOD RD
Practice Address - Street 2:
Practice Address - City:BOURNE
Practice Address - State:MA
Practice Address - Zip Code:02532-2227
Practice Address - Country:US
Practice Address - Phone:617-839-3429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10226991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06613Medicare ID - Type Unspecified