MEDICARE: MRS. KIMBERLY DIANE MOORE

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	:	1669598215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY DIANE MOORE

Provider Business Mailing Address
First Line	:	11300 ACACIA AVE
Second Line	:
City	:	INGLEWOOD
State	:	CA
Zip	:	90304-2800
Country	:	US
Telephone Number	:	323-252-4610
Fax Number	:

Provider Business Practice Location Address
First Line	:	6838 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7008
Country	:	US
Telephone Number	:	323-252-4610
Fax Number	:

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

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/30/2014

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