MEDICARE: DR. MARY E MOORE PHD

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	103T00000X	Psychologist	PSY10159	CA

General Provider Information

NPI Number	:	1871799957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY E MOORE PHD

Provider Business Mailing Address
First Line	:	325 W HOSPITALITY LANE
Second Line	:	SUITE 310
City	:	SAN BERNANDINO
State	:	CA
Zip	:	92408-3212
Country	:	US
Telephone Number	:	909-386-5500
Fax Number	:	909-386-5520

Provider Business Practice Location Address
First Line	:	325 W HOSPITALITY LANE
Second Line	:	SUITE 310
City	:	SAN BERNANDINO
State	:	CA
Zip	:	92408-3212
Country	:	US
Telephone Number	:	909-386-5500
Fax Number	:	909-386-5520

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/08/2007

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