Provider Demographics
NPI:1750640009
Name:MOORE, MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
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 1:10556 E CAROLINA WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-9537
Mailing Address - Country:US
Mailing Address - Phone:601-520-1438
Mailing Address - Fax:
Practice Address - Street 1:10556 E CAROLINA WILLOW LN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-9537
Practice Address - Country:US
Practice Address - Phone:601-520-1438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-07
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist