Provider Demographics
NPI:1427280155
Name:MOORE, DOUGLAS JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JOHN
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 1:6611 ROCKSIDE RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2365
Mailing Address - Country:US
Mailing Address - Phone:216-462-0538
Mailing Address - Fax:
Practice Address - Street 1:6611 ROCKSIDE RD
Practice Address - Street 2:SUITE 215
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2365
Practice Address - Country:US
Practice Address - Phone:216-462-0538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2009-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical