Provider Demographics
NPI:1336709054
Name:MOORE, DION RAY
Entity type:Individual
Prefix:
First Name:DION
Middle Name:RAY
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 1:1601 2ND ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2701
Mailing Address - Country:US
Mailing Address - Phone:415-454-9444
Mailing Address - Fax:
Practice Address - Street 1:1601 2ND ST STE 104
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2701
Practice Address - Country:US
Practice Address - Phone:415-454-9444
Practice Address - Fax:415-454-9444
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)