Healthcare Provider Details

I. General information

NPI: 1598057291
Provider Name (Legal Business Name): CYNTHIA CHASE MOORE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

49 ASTORIA CIR
PETALUMA CA
94954-4669
US

V. Phone/Fax

Practice location:
  • Phone: 707-651-1000
  • Fax:
Mailing address:
  • Phone: 707-762-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS9527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: