Provider Demographics
NPI:1841340601
Name:MOORE, MITCHELL JAT (LADC)
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:JAT
Last Name:MOORE
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 WOODDALE CT NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-2472
Mailing Address - Country:US
Mailing Address - Phone:507-282-6075
Mailing Address - Fax:
Practice Address - Street 1:923 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-6843
Practice Address - Country:US
Practice Address - Phone:507-281-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300769101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)