Healthcare Provider Details

I. General information

NPI: 1295889756
Provider Name (Legal Business Name): SUSAN DIAMOND MOORE L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 DANA ST
BERKELEY CA
94705-2041
US

IV. Provider business mailing address

3001 DANA ST
BERKELEY CA
94705-2041
US

V. Phone/Fax

Practice location:
  • Phone: 510-841-6006
  • Fax: 510-635-2440
Mailing address:
  • Phone: 510-841-6006
  • Fax: 510-635-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS13905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: