1225032865 NPI number — STEPHANIE MOORE PSYD

Table of content: STEPHANIE MOORE PSYD (NPI 1225032865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225032865 NPI number — STEPHANIE MOORE PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
STEPHANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225032865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24992 KATIE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-280-7984
Provider Business Mailing Address Fax Number:
949-474-1174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 N TUSTIN AVE
Provider Second Line Business Practice Location Address:
#603
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-731-6231
Provider Business Practice Location Address Fax Number:
714-731-6283
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  PSY14222 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PSY14222 . This is a "LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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