Provider Demographics
NPI:1285948919
Name:MOORE, STEPHEN D
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1044
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-1044
Mailing Address - Country:US
Mailing Address - Phone:575-336-1006
Mailing Address - Fax:
Practice Address - Street 1:206 PORR DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6713
Practice Address - Country:US
Practice Address - Phone:575-630-0571
Practice Address - Fax:575-630-0574
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor