Healthcare Provider Details

I. General information

NPI: 1033475850
Provider Name (Legal Business Name): CARL MOORE CDP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2012
Last Update Date: 02/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 MLK JR WAY S
SEATTLE WA
98144-4801
US

IV. Provider business mailing address

3629 S D ST
TACOMA WA
98418-6813
US

V. Phone/Fax

Practice location:
  • Phone: 206-322-7676
  • Fax: 206-726-7585
Mailing address:
  • Phone: 253-798-6572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP 00006161
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: