Provider Demographics
NPI:1215143821
Name:MOORE, LAWRENCE HAROLD (PHD)
Entity type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:HAROLD
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 1:2009 F STREET
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663
Mailing Address - Country:US
Mailing Address - Phone:360-693-3715
Mailing Address - Fax:360-737-8269
Practice Address - Street 1:2009 F STREET
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3345
Practice Address - Country:US
Practice Address - Phone:360-693-3715
Practice Address - Fax:360-737-8269
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2014103G00000X
OR1515103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA169713OtherDEPT OF LABOR & INDUSTRIE
WA7078918Medicaid
WA8800636Medicare PIN