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NPI Code Detail

MEDICARE: DR. MARIE C MOORE PH.D.

MEDICARE: DR. MARIE C MOORE PH.D.
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
1103TC0700XClinical PsychologistPSY15404CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PSY15404OTHERCALICENSE

General Provider Information

NPI Number : 1639211493
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. MARIE C MOORE PH.D.
Provider Business Mailing Address
First Line : 1145 GAYLEY AVE
Second Line : SUITE 322
City : LOS ANGELES
State : CA
Zip : 90024-3423
Country : US
Telephone Number : 310-991-5720
Fax Number : 310-208-0684
Provider Business Practice Location Address
First Line : 1145 GAYLEY AVE
Second Line : SUITE 322
City : LOS ANGELES
State : CA
Zip : 90024-3423
Country : US
Telephone Number : 310-991-5720
Fax Number : 310-208-0684
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/12/2007
Last Update Date : 07/08/2007

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