Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 102L00000X | Psychologist | PSY001097 | GA |
N | 103T00000X | Psychologist | PSY001097 | GA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | PSY001097 | GA |
NPI | 1538382908 |
---|---|
Provider Name | Dr. Brian Lee Moore |
First Address | Marietta, GA 30061-3152 |
Second Address | Atlanta, GA 30339-5980 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/04/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
68BBCSG | (05) | GA |