Provider Demographics
NPI:1942009808
Name:MOORE, THOMAS WILLIAM
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N COLLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1632
Mailing Address - Country:US
Mailing Address - Phone:407-461-2960
Mailing Address - Fax:
Practice Address - Street 1:100 N COLLINGTON AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1632
Practice Address - Country:US
Practice Address - Phone:407-461-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP16233101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health