Healthcare Provider Details

I. General information

NPI: 1104551803
Provider Name (Legal Business Name): ANNA-MAE EVANGELINE CONRAD MOORE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNA MAE EVANGELINE CONRAD

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58923 BUSINESS CENTER DR STE A-E
YUCCA VALLEY CA
92284-7311
US

IV. Provider business mailing address

58923 BUSINESS CENTER DR STE A-E
YUCCA VALLEY CA
92284-7311
US

V. Phone/Fax

Practice location:
  • Phone: 760-365-7209
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW108530
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW108530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: