Provider Demographics
NPI:1265302517
Name:MOORE, JOHN CAMDEN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CAMDEN
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 1:1208 HILLTOP DR STE 103
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5858
Mailing Address - Country:US
Mailing Address - Phone:307-212-8015
Mailing Address - Fax:307-224-2128
Practice Address - Street 1:1208 HILLTOP DR STE 103
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5858
Practice Address - Country:US
Practice Address - Phone:307-212-8015
Practice Address - Fax:307-224-2128
Is Sole Proprietor?:No
Enumeration Date:2025-11-10
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical