Provider Demographics
NPI:1306311394
Name:MOORE, KATIE EMILY (AAS, CDPT)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:EMILY
Last Name:MOORE
Suffix:
Gender:F
Credentials:AAS, CDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21917 NE 209TH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604-4920
Mailing Address - Country:US
Mailing Address - Phone:360-524-5703
Mailing Address - Fax:
Practice Address - Street 1:11910 NE 154TH ST
Practice Address - Street 2:
Practice Address - City:BRUSH PRAIRIE
Practice Address - State:WA
Practice Address - Zip Code:98606-9571
Practice Address - Country:US
Practice Address - Phone:360-750-9588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60779419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)