Healthcare Provider Details

I. General information

NPI: 1982158481
Provider Name (Legal Business Name): YANCY MOORE CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SIMPSON AVENUE SUITE 101
ABERDEEN WA
98520
US

IV. Provider business mailing address

921 14TH AVENUE
LONGVIEW WA
98632
US

V. Phone/Fax

Practice location:
  • Phone: 360-612-0012
  • Fax: 360-218-5945
Mailing address:
  • Phone: 360-423-0203
  • Fax: 360-577-0269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60186868
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: