Provider Demographics
NPI:1770937732
Name:PICKENS MOORE
Entity type:Organization
Organization Name:PICKENS MOORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LISW
Authorized Official - Prefix:MR
Authorized Official - First Name:PICKENS
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-863-7472
Mailing Address - Street 1:3306 CHURCH ROCK ST
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-4506
Mailing Address - Country:US
Mailing Address - Phone:505-863-7472
Mailing Address - Fax:505-863-7472
Practice Address - Street 1:100 E AZTEC AVE
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6256
Practice Address - Country:US
Practice Address - Phone:505-863-7472
Practice Address - Fax:505-863-7472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-15
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-3118104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NML9282Medicaid