Provider Demographics
NPI:1093188260
Name:MOORE, GABRIELLE L
Entity Type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6222 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5123
Mailing Address - Country:US
Mailing Address - Phone:323-902-7686
Mailing Address - Fax:
Practice Address - Street 1:6222 WILSHIRE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:323-902-7686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF69106106H00000X
CAMFC104756106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist