Healthcare Provider Details

I. General information

NPI: 1225659519
Provider Name (Legal Business Name): MICHAEL THOMAS MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 BELVIEW ST. SE
WASHINGTON DC
20032
US

IV. Provider business mailing address

15616 GILPIN MEWS LN
BRANDYWINE MD
20613-6277
US

V. Phone/Fax

Practice location:
  • Phone: 202-562-4939
  • Fax:
Mailing address:
  • Phone: 240-893-2491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCACI1135
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: