Provider Demographics
NPI:1740072305
Name:MOORE, EVERRETT (PHD)
Entity type:Individual
Prefix:DR
First Name:EVERRETT
Middle Name:
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 1:1130 N KIMBALL AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-4745
Mailing Address - Country:US
Mailing Address - Phone:940-278-8664
Mailing Address - Fax:
Practice Address - Street 1:1130 N KIMBALL AVE STE 120
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-4745
Practice Address - Country:US
Practice Address - Phone:940-278-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-20
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40164103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist