Healthcare Provider Details

I. General information

NPI: 1174586598
Provider Name (Legal Business Name): TERRY WILLIAM MOORE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 N KENDRICK ST
FLAGSTAFF AZ
86001-1582
US

IV. Provider business mailing address

2224 N LANTERN LN
FLAGSTAFF AZ
86001-1133
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-6364
  • Fax: 928-556-0504
Mailing address:
  • Phone: 928-774-6824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number33811
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1098
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number172
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: