Provider Demographics
NPI:1679699151
Name:MOORE, JOHN THOMAS (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
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 1:507 RUBYTHROAT LN
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45315-8742
Mailing Address - Country:US
Mailing Address - Phone:937-832-0572
Mailing Address - Fax:
Practice Address - Street 1:498 NW 18TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-2851
Practice Address - Country:US
Practice Address - Phone:765-935-9317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20010430A103TC0700X
OH5174103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical