Healthcare Provider Details

I. General information

NPI: 1609545581
Provider Name (Legal Business Name): GRADI MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16940 HIGHWAY 14 STE C-J
MOJAVE CA
93501-1238
US

IV. Provider business mailing address

PO BOX 2502
CALIFORNIA CITY CA
93504-0502
US

V. Phone/Fax

Practice location:
  • Phone: 661-824-5020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW136114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: