Provider Demographics
NPI:1164739595
Name:MOORE-EMMETT, ANDREA G (LMFT)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:G
Last Name:MOORE-EMMETT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9330 BASELINE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91701-5827
Mailing Address - Country:US
Mailing Address - Phone:909-303-0960
Mailing Address - Fax:877-560-5695
Practice Address - Street 1:9330 BASELINE RD STE 102
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91701
Practice Address - Country:US
Practice Address - Phone:909-303-0960
Practice Address - Fax:877-560-5695
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-07
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA97170101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1164739595Medicaid