Provider Demographics
NPI:1336413731
Name:MOORE, JOHN MICHAEL (LAPC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:MOORE
Suffix:
Gender:M
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3643 WALTON WAY EXT
Mailing Address - Street 2:BLDG
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4507
Mailing Address - Country:US
Mailing Address - Phone:706-421-6039
Mailing Address - Fax:
Practice Address - Street 1:3643 WALTON WAY EXT
Practice Address - Street 2:BLDG
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4507
Practice Address - Country:US
Practice Address - Phone:706-421-6039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC002693101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional