Provider Demographics
NPI:1770706053
Name:MOORE, PETER
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12920 DAIRY ASHFORD RD STE 105
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3178
Mailing Address - Country:US
Mailing Address - Phone:832-372-6844
Mailing Address - Fax:
Practice Address - Street 1:12920 DAIRY ASHFORD RD STE 105
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3178
Practice Address - Country:US
Practice Address - Phone:832-372-6844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3-0929103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX51ESOtherBLUE CROSS BLUE SHIELD
TX144475401Medicaid