Provider Demographics
NPI:1780823575
Name:MOORE, RAY A (CAC III)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W C ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3409
Mailing Address - Country:US
Mailing Address - Phone:719-296-1366
Mailing Address - Fax:719-296-6825
Practice Address - Street 1:310 W C ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3409
Practice Address - Country:US
Practice Address - Phone:719-296-1366
Practice Address - Fax:719-296-6825
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6281101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1447389382Medicaid