Healthcare Provider Details

I. General information

NPI: 1548787765
Provider Name (Legal Business Name): BRENDA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 PACIFIC AVE S STE 102
KELSO WA
98626-1638
US

IV. Provider business mailing address

PO BOX 1847
LONGVIEW WA
98632-8140
US

V. Phone/Fax

Practice location:
  • Phone: 360-577-7442
  • Fax: 360-577-7904
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 NumberCP00002285
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: