Healthcare Provider Details

I. General information

NPI: 1992201917
Provider Name (Legal Business Name): KAYLA D MOORER PHD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PAGE DR S STE 102A
FARGO ND
58103-3562
US

IV. Provider business mailing address

1204 12TH ST S
MOORHEAD MN
56560-3708
US

V. Phone/Fax

Practice location:
  • Phone: 701-478-6604
  • Fax:
Mailing address:
  • Phone: 601-580-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number2949
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number2949
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number564
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: