=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548658537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER MOORE LMFT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/30/2014
-----------------------------------------------------
Last Update Date | 12/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 E ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-0313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-442-7228
-----------------------------------------------------
Fax | 707-442-7228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 74
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95502-0074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-442-7228
-----------------------------------------------------
Fax | 707-442-7228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LMFT23507
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------