Healthcare Provider Details

I. General information

NPI: 1083757876
Provider Name (Legal Business Name): KIMBERLY A. MOORE ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 N GRAND AVE SUITE D
COVINA CA
91724-1551
US

IV. Provider business mailing address

1126 N GRAND AVE SUITE D
COVINA CA
91724-1551
US

V. Phone/Fax

Practice location:
  • Phone: 626-967-1667
  • Fax: 626-967-6027
Mailing address:
  • Phone: 626-967-1667
  • Fax: 626-967-6027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberACSW24402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: