=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609425065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUISE MOORE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2019
-----------------------------------------------------
Last Update Date | 09/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 4TH ST STE 13
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-774-1225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 4TH ST STE 13
-----------------------------------------------------
City | PETALUMA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94952-3072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-774-1225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MFT
-----------------------------------------------------
Name | LOUISE MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-774-1225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------