Provider Demographics
NPI:1336885813
Name:MOORE, MICAH (LMFT CANDIDATE)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:LMFT CANDIDATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-5017
Mailing Address - Country:US
Mailing Address - Phone:580-924-4779
Mailing Address - Fax:580-924-4779
Practice Address - Street 1:114 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-5017
Practice Address - Country:US
Practice Address - Phone:580-924-4779
Practice Address - Fax:580-924-4779
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty