Basic Information
| Provider Information | |||||||||
| NPI: | 1508367798 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | OLIVER | ||||||||
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| NameSuffix: | IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2043 ST. NICK DR/P: G4 N4, DURING THE 12 MONTHS DURING | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5045122120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1995 GENTILLY BLVD | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701191700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5049440453 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2018 | ||||||||
| LastUpdateDate: | 02/23/2018 | ||||||||
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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 | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.