Provider Demographics
NPI:1164541330
Name:MOORE, MICHAEL SINCLAIR (LMFT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SINCLAIR
Last Name:MOORE
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1172 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4236
Mailing Address - Country:US
Mailing Address - Phone:818-765-8656
Mailing Address - Fax:
Practice Address - Street 1:1172 N MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-1328
Practice Address - Country:US
Practice Address - Phone:818-765-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2013-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC52167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist