MEDICARE: STEPHANIE MOORE PSYD

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	103G00000X	Clinical Neuropsychologist	PSY14222	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PSY14222	OTHER	CA	LICENSE

General Provider Information

NPI Number	:	1225032865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MOORE PSYD

Provider Business Mailing Address
First Line	:	24992 KATIE AVE
Second Line	:
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92053
Country	:	US
Telephone Number	:	949-280-7984
Fax Number	:	949-474-1174

Provider Business Practice Location Address
First Line	:	801 N TUSTIN AVE
Second Line	:	#603
City	:	SANTA ANA
State	:	CA
Zip	:	92705-3612
Country	:	US
Telephone Number	:	714-731-6231
Fax Number	:	714-731-6283

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	05/12/2010

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Directions to “ STEPHANIE MOORE PSYD” Practice Location

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