Healthcare Provider Details

I. General information

NPI: 1275758690
Provider Name (Legal Business Name): MAGGIE MOORE LMFI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 2
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

9825 MAGNOLIA AVE STE B
RIVERSIDE CA
92503-3565
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2499
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number117663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: