MEDICARE: MS. ALLYSON GAYLE MOORE M.S., BCBA, LMFT

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	103K00000X	Behavior Analyst	1-04-2053	CA
2	106H00000X	Marriage & Family Therapist	48029	CA

General Provider Information

NPI Number	:	1578857801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ALLYSON GAYLE MOORE M.S., BCBA, LMFT

Provider Business Mailing Address
First Line	:	PO BOX 189
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94942-0189
Country	:	US
Telephone Number	:	510-331-8490
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 PERALTA AVE
Second Line	:
City	:	MILL VALLEY
State	:	CA
Zip	:	94941-3519
Country	:	US
Telephone Number	:	510-331-8490
Fax Number	:

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

Provider Enumeration Date	:	06/03/2011
Last Update Date	:	03/23/2017

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