Provider Demographics
NPI:1972705028
Name:MOORE, TOM LEROY (MFT)
Entity Type:Individual
Prefix:MRS
First Name:TOM
Middle Name:LEROY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21801 E 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:CA
Mailing Address - Zip Code:95236-9736
Mailing Address - Country:US
Mailing Address - Phone:209-887-3218
Mailing Address - Fax:
Practice Address - Street 1:7000 MICHAEL CANLIS WAY
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9781
Practice Address - Country:US
Practice Address - Phone:209-468-5505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43541106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist