Healthcare Provider Details

I. General information

NPI: 1467771436
Provider Name (Legal Business Name): PATRICIA ANN MOORE CDP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 LILLY RD NE STE C
OLYMPIA WA
98506-5080
US

IV. Provider business mailing address

200 LILLY RD NE
OLYMPIA WA
98506-5427
US

V. Phone/Fax

Practice location:
  • Phone: 360-918-8336
  • Fax: 360-972-2152
Mailing address:
  • Phone: 360-918-8336
  • Fax: 360-972-2152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP60119738
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: