=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801171442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TATIANA M. MOORE MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2011
-----------------------------------------------------
Last Update Date | 02/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4002 PARK BLVD STE C
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-271-2629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 924
-----------------------------------------------------
City | PAUMA VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92061-0924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-271-2629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 53451
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------