MEDICARE: MARICELA MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	ASW63465	CA
2	1041C0700X	Clinical Social Worker	76571	CA

General Provider Information

NPI Number	:	1154603504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARICELA MOORE

Provider Business Mailing Address
First Line	:	995 GATEWAY CENTER WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-4500
Country	:	US
Telephone Number	:	619-398-2156
Fax Number	:

Provider Business Practice Location Address
First Line	:	4995 MURPHY CANYON RD STE 201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-4365
Country	:	US
Telephone Number	:	619-884-5149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	10/28/2018

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Directions to “ MARICELA MOORE ” Practice Location

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