Healthcare Provider Details

I. General information

NPI: 1679934608
Provider Name (Legal Business Name): THOMAS IAN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2016
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 JEFFERSON ST
SAN DIEGO CA
92110-4421
US

IV. Provider business mailing address

3132 JEFFERSON ST
SAN DIEGO CA
92110-4421
US

V. Phone/Fax

Practice location:
  • Phone: 619-683-3100
  • Fax:
Mailing address:
  • Phone: 619-683-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW70618
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: