Provider Demographics
NPI:1265535231
Name:DAVID B MOORE, PHD, PSC
Entity type:Organization
Organization Name:DAVID B MOORE, PHD, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:502-819-8300
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 CIRCLE
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:502-819-8300
Practice Address - Fax:502-499-4431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
KY0247106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8290014300Medicaid
KY8290014300Medicaid
KY0713201Medicare PIN
KY7132Medicare PIN