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General NPI Number Information
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NPI Number | 1487125480
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Entity Type | Individual
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Provider Name | JOHN MOORE III PHD
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Gender | Male
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Dates
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Enumeration Date | 12/17/2018
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 1000 BROADWAY STE 460
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City | OAKLAND
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State | CA
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Zip | 94607-4033
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Country | US
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Telephone | 510-506-1719
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Fax | 510-465-5520
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Provider Business Mailing Address
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Address Line | 1000 BROADWAY STE 460
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City | OAKLAND
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State | CA
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Zip | 94607-4033
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Country | US
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Telephone | 510-506-1719
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Fax | 510-465-5520
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 29285
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License Number State | CA
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