Provider Demographics
NPI:1356069637
Name:MOORE, LAROY J (PSYS)
Entity type:Individual
Prefix:
First Name:LAROY
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4931 KATHRYN CIR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3501
Mailing Address - Country:US
Mailing Address - Phone:505-436-6684
Mailing Address - Fax:
Practice Address - Street 1:10320 COTTONWOOD PARK NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-7008
Practice Address - Country:US
Practice Address - Phone:505-250-5204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM349297103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool