Healthcare Provider Details

I. General information

NPI: 1992524755
Provider Name (Legal Business Name): RON LARON MOORE T-24-4482 CADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RON LARON MOORE 25-QMHPC-001654

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 03/06/2026
Certification Date: 03/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58646 MCNULTY WAY
SAINT HELENS OR
97051-6210
US

IV. Provider business mailing address

58646 MCNULTY WAY
SAINT HELENS OR
97051-6210
US

V. Phone/Fax

Practice location:
  • Phone: 503-397-5211
  • Fax: 503-397-5373
Mailing address:
  • Phone: 503-397-5211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: