Healthcare Provider Details

I. General information

NPI: 1881745321
Provider Name (Legal Business Name): BONNIE RAE MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 W OLIVE AVE
BURBANK CA
91506-2628
US

IV. Provider business mailing address

2312 W OLIVE AVE
BURBANK CA
91506-2628
US

V. Phone/Fax

Practice location:
  • Phone: 818-885-1290
  • Fax: 818-885-0319
Mailing address:
  • Phone: 818-885-1290
  • Fax: 818-885-0319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW 8385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: