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General NPI Number Information
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NPI Number | 1902203847
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Entity Type | Individual
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Provider Name | DIANA MOORE PHD
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Gender | Female
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Dates
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Enumeration Date | 11/20/2014
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Last Update Date | 11/02/2016
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Provider Practice Location Address
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Address Line | 1323 BIA RD. 20
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City | FORT THOMSPSON
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State | SD
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Zip | 57339
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Country | US
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Telephone | 605-245-1525
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Fax |
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Provider Business Mailing Address
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Address Line | 1323 BIA RD. 20
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City | FORT THOMSPSON
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State | SD
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Zip | 57339
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Country | US
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Telephone | 605-245-1525
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Fax |
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2506
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License Number State | OR
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