Provider Demographics
NPI:1194094045
Name:MOORE, TIMOTHY RICHARD (PHD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:MOORE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 UNIVERSITY AVE SE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3325
Mailing Address - Country:US
Mailing Address - Phone:612-331-9413
Mailing Address - Fax:612-728-5301
Practice Address - Street 1:3333 UNIVERSITY AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3325
Practice Address - Country:US
Practice Address - Phone:612-331-9413
Practice Address - Fax:612-728-5301
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5453103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist