Provider Demographics
NPI:1538598487
Name:MOORE, THOMAS (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 N SANGAMON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2201
Mailing Address - Country:US
Mailing Address - Phone:309-397-2415
Mailing Address - Fax:
Practice Address - Street 1:66 CLUB RD STE 140
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2491
Practice Address - Country:US
Practice Address - Phone:541-345-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61231272163W00000X
OR202002591RN163W00000X
IL041393235163WP0808X
WAAP61231376363LP0808X, 363LP0808X
IL209017885363LP0808X
OR202002776NP-PP363LP0808X, 363LP0808X
CO0995181363LP0808X
IAG151271363LP0808X
AZAP7277363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500778964Medicaid
OR500801827Medicaid