Provider Demographics
NPI:1205599065
Name:MOORE, THOMAS
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 LOS LENTES RD SE STE 3
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6018
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2504 CAMINO ENTRADA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-4851
Practice Address - Country:US
Practice Address - Phone:774-267-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator