Healthcare Provider Details

I. General information

NPI: 1497942239
Provider Name (Legal Business Name): MRS. CYNTHIA RENEE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1630 E SHAW SUITE 150
FRESNO CA
93710
US

IV. Provider business mailing address

1630 E. SHAW SUITE 150
FRESNO CA
93710
US

V. Phone/Fax

Practice location:
  • Phone: 559-248-8550
  • Fax: 559-248-8555
Mailing address:
  • Phone: 559-248-8550
  • Fax: 559-248-8555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: