Provider Demographics
NPI:1093222010
Name:MOORE, LEYONITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEYONITA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LEYA
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 7236
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53707-7236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 E CAMPUS MALL 7TH FLR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715
Practice Address - Country:US
Practice Address - Phone:608-265-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-29
Last Update Date:2023-09-29
Deactivation Date:2020-11-11
Deactivation Code:
Reactivation Date:2020-12-07
Provider Licenses
StateLicense IDTaxonomies
NY021049-1103TC1900X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3920OtherLICENSE
56974OtherNATIONAL REGISTER OF HEALTH SERVICE PSYCHOLOGISTS
NY021049OtherLICENSE