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General NPI Number Information
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NPI Number | 1518672120
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Entity Type | Individual
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Provider Name | DUSTIN BURSON MOORE
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Gender | Male
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Dates
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Enumeration Date | 01/18/2023
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Last Update Date | 07/19/2023
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Provider Practice Location Address
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Address Line | 630 ADDISON AVE W STE 1000
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City | TWIN FALLS
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State | ID
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Zip | 83301-5853
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Country | US
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Telephone | 208-736-5048
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Fax |
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Provider Business Mailing Address
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Address Line | 776 N POINTE DR
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City | TWIN FALLS
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State | ID
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Zip | 83301-3285
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Country | US
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Telephone | 360-751-4313
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC-9658
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License Number State | ID
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