Provider Demographics
NPI:1760585798
Name:MOORE, DAVID BRUCE (PHD, LCSW,BCD, BCN)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRUCE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD, LCSW,BCD, BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 STONY SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-5428
Mailing Address - Country:US
Mailing Address - Phone:502-819-8300
Mailing Address - Fax:502-499-4431
Practice Address - Street 1:3400 STONY SPRING CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-5428
Practice Address - Country:US
Practice Address - Phone:502-499-4160
Practice Address - Fax:502-499-4431
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002233A1041C0700X
KY5061041C0700X
KY0247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8290014300Medicaid
KYR36242Medicare UPIN
KY8290014300Medicaid
KY7132Medicare PIN