Healthcare Provider Details

I. General information

NPI: 1093222010
Provider Name (Legal Business Name): LEYONITA MOORE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LEYA MOORE PHD

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date: 11/11/2020
Reactivation Date: 12/07/2020

III. Provider practice location address

333 E CAMPUS MALL 7TH FLR
MADISON WI
53715
US

IV. Provider business mailing address

PO BOX 7236
MADISON WI
53707-7236
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number021049-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number021049-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: