Healthcare Provider Details

I. General information

NPI: 1659753929
Provider Name (Legal Business Name): LAURA MOORE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S MAIN ST STE 201
CORONA CA
92882-5303
US

IV. Provider business mailing address

PO BOX 4082
RANCHO CUCAMONGA CA
91729-4082
US

V. Phone/Fax

Practice location:
  • Phone: 951-279-3222
  • Fax: 951-279-5222
Mailing address:
  • Phone: 909-532-9153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number87352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: