Healthcare Provider Details

I. General information

NPI: 1356069637
Provider Name (Legal Business Name): LAROY J MOORE PSYS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10320 COTTONWOOD PARK NW STE A
ALBUQUERQUE NM
87114-7008
US

IV. Provider business mailing address

4931 KATHRYN CIR SE
ALBUQUERQUE NM
87108-3501
US

V. Phone/Fax

Practice location:
  • Phone: 505-250-5204
  • Fax:
Mailing address:
  • Phone: 505-436-6684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number349297
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: