Provider Demographics
NPI:1386962355
Name:MOORE, ERIK (PHD)
Entity type:Individual
Prefix:
First Name:ERIK
Middle Name:
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 1:755 NARROWS RD N APT 507
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1533
Mailing Address - Country:US
Mailing Address - Phone:718-966-5217
Mailing Address - Fax:718-374-6121
Practice Address - Street 1:755 NARROWS RD N APT 507
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1533
Practice Address - Country:US
Practice Address - Phone:718-966-5217
Practice Address - Fax:718-374-6121
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-14
Last Update Date:2010-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03081789Medicaid