Provider Demographics
NPI:1124465679
Name:MOORE, ANDRE ANTHONY (MA)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:ANTHONY
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 BLEECKER STREET
Mailing Address - Street 2:9 C EAST
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012
Mailing Address - Country:US
Mailing Address - Phone:212-673-4618
Mailing Address - Fax:
Practice Address - Street 1:160 BLEECKER ST
Practice Address - Street 2:9 C EAST
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-1541
Practice Address - Country:US
Practice Address - Phone:212-673-4618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR016091P101Y00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2128967OtherUNITED HEALTH CARE - OXFORD