Healthcare Provider Details

I. General information

NPI: 1861595423
Provider Name (Legal Business Name): DARRYL KENNETH MOORE PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 CAMINO DEL RIO S STE 220
SAN DIEGO CA
92108
US

IV. Provider business mailing address

3110 CAMINO DEL RIO S STE 220
SAN DIEGO CA
92108-3831
US

V. Phone/Fax

Practice location:
  • Phone: 858-433-8751
  • Fax: 858-433-0118
Mailing address:
  • Phone: 858-433-8751
  • Fax: 858-433-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPSY22459
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY22459
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: