Healthcare Provider Details

I. General information

NPI: 1255217824
Provider Name (Legal Business Name): TIMOTHY M MOORE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 W HOOD AVE
SISTERS OR
97759-1529
US

IV. Provider business mailing address

704 W HOOD AVE
SISTERS OR
97759-1529
US

V. Phone/Fax

Practice location:
  • Phone: 541-280-5210
  • Fax: 541-280-5210
Mailing address:
  • Phone: 541-280-5210
  • Fax: 541-280-5210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY M MOORE
Title or Position: CLINICAL DIRECTOR/OWNER
Credential: LPC
Phone: 541-280-5210