Basic Information
| Provider Information | |||||||||
| NPI: | 1508121302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 490 S FARRELL DR | ||||||||
| Address2: | STE. C- 208 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922627992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603254088 | ||||||||
| FaxNumber: | 7607799403 | ||||||||
| Practice Location | |||||||||
| Address1: | 490 S FARRELL DR | ||||||||
| Address2: | STE. 202 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922627992 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603254088 | ||||||||
| FaxNumber: | 7607799403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2012 | ||||||||
| LastUpdateDate: | 06/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 17927 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.