Provider Demographics
NPI:1982737011
Name:MOORE, C L (PHD LP LMFT)
Entity Type:Individual
Prefix:DR
First Name:C
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD LP LMFT
Other - Prefix:DR
Other - First Name:C
Other - Middle Name:L
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD LP LMFT
Mailing Address - Street 1:2440 NORTH CHARLES ST
Mailing Address - Street 2:STE 236
Mailing Address - City:N ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109
Mailing Address - Country:US
Mailing Address - Phone:651-771-4766
Mailing Address - Fax:651-771-4784
Practice Address - Street 1:2440 NORTH CHARLES ST
Practice Address - Street 2:STE 236
Practice Address - City:N ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109
Practice Address - Country:US
Practice Address - Phone:651-771-4766
Practice Address - Fax:651-771-4784
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2246103T00000X
WAPY00000625103T00000X
CO440103T00000X
MN1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN104097OtherU CARE
WI39036800OtherWI MEDICAID
MN212T8PEOtherBC BS BT
MN6049644OtherSTATE OF MN
MNHP19293OtherHEALTH PARTNERS