MEDICARE: REBECCA ALICE MOORE M.ED.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1285963348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA ALICE MOORE M.ED.

Provider Business Mailing Address
First Line	:	109 1/2 N MALIN RD
Second Line	:
City	:	BROOMALL
State	:	PA
Zip	:	19008-1535
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 OLD EAGLE SCHOOL RD
Second Line	:	2ND FLOOR
City	:	STRAFFORD
State	:	PA
Zip	:	19087-2556
Country	:	US
Telephone Number	:	610-688-1636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2009
Last Update Date	:	12/18/2009

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