Healthcare Provider Details

I. General information

NPI: 1598631434
Provider Name (Legal Business Name): MR. CODY J MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2025
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E 4TH ST
SANTA ANA CA
92705-3910
US

IV. Provider business mailing address

1900 E 4TH ST
SANTA ANA CA
92705-3910
US

V. Phone/Fax

Practice location:
  • Phone: 833-579-4848
  • Fax: 714-967-4575
Mailing address:
  • Phone: 833-579-4848
  • Fax: 714-967-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT158413
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: