Provider Demographics
NPI:1538382908
Name:MOORE, BRIAN LEE (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEE
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:PO BOX 3152
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30061-3152
Mailing Address - Country:US
Mailing Address - Phone:770-590-4441
Mailing Address - Fax:
Practice Address - Street 1:400 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 1500
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5980
Practice Address - Country:US
Practice Address - Phone:770-590-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001097103T00000X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCSGMedicaid
GA00637854AMedicare ID - Type UnspecifiedMEDICARE