Healthcare Provider Details

I. General information

NPI: 1831290444
Provider Name (Legal Business Name): TIMOTHY MOORE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13549 N SANDERS RD
MARANA AZ
85653
US

IV. Provider business mailing address

PO BOX 188
MARANA AZ
85653-0188
US

V. Phone/Fax

Practice location:
  • Phone: 520-682-1091
  • Fax:
Mailing address:
  • Phone: 520-818-3616
  • Fax: 520-818-3630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10344
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLPC12099
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC12099
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: