Healthcare Provider Details

I. General information

NPI: 1376605584
Provider Name (Legal Business Name): ROSS EVON MOORE MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 BECK AVE
FAIRFIELD CA
94533-4440
US

IV. Provider business mailing address

536 OAKMEADOW CT
VACAVILLE CA
95687-7111
US

V. Phone/Fax

Practice location:
  • Phone: 707-784-6570
  • Fax: 707-784-2720
Mailing address:
  • Phone: 707-446-6060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC 42879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: