Healthcare Provider Details

I. General information

NPI: 1225032865
Provider Name (Legal Business Name): STEPHANIE MOORE PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N TUSTIN AVE #603
SANTA ANA CA
92705-3612
US

IV. Provider business mailing address

24992 KATIE AVE
LAGUNA HILLS CA
92053
US

V. Phone/Fax

Practice location:
  • Phone: 714-731-6231
  • Fax: 714-731-6283
Mailing address:
  • Phone: 949-280-7984
  • Fax: 949-474-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY14222
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: