Basic Information
| Provider Information | |||||||||
| NPI: | 1417382615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | TAYLOR | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18202 W 20TH ST N | ||||||||
| Address2: | |||||||||
| City: | HASKELL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744362800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186393903 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 ARROWHEAD DR | ||||||||
| Address2: | |||||||||
| City: | PAULS VALLEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730755301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053312300 | ||||||||
| FaxNumber: | 4053312302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2013 | ||||||||
| LastUpdateDate: | 09/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.