Healthcare Provider Details

I. General information

NPI: 1124065818
Provider Name (Legal Business Name): ANNA B MOORE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CLIFTON RD NE
ATLANTA GA
30322-1004
US

IV. Provider business mailing address

1365 CLIFTON RD NE
ATLANTA GA
30322-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-5512
  • Fax: 404-778-4819
Mailing address:
  • Phone: 404-778-7402
  • Fax: 404-778-4819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPSY0002953
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: