Provider Demographics
NPI:1174586598
Name:MOORE, TERRY WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 N LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1133
Mailing Address - Country:US
Mailing Address - Phone:928-774-6824
Mailing Address - Fax:
Practice Address - Street 1:408 N KENDRICK ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1582
Practice Address - Country:US
Practice Address - Phone:928-774-6364
Practice Address - Fax:928-556-0504
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY33811101YM0800X
AZ1098103TC1900X
WY172103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ64056Medicare UPIN