Provider Demographics
NPI:1548679384
Name:MOORE, MARK (MA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9533 ROOSEVELT DR
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-4612
Mailing Address - Country:US
Mailing Address - Phone:952-250-0602
Mailing Address - Fax:
Practice Address - Street 1:540 E 1ST ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387
Practice Address - Country:US
Practice Address - Phone:952-442-4437
Practice Address - Fax:952-442-3084
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health