Healthcare Provider Details

I. General information

NPI: 1376156943
Provider Name (Legal Business Name): SAMUEL THOMAS MOORE M.ED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8931 HURON ST
THORNTON CO
80260-6806
US

IV. Provider business mailing address

9943 E ALABAMA CIR APT 1426
AURORA CO
80247-6361
US

V. Phone/Fax

Practice location:
  • Phone: 303-853-3500
  • Fax:
Mailing address:
  • Phone: 918-949-8245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0016398
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: