Provider Demographics
NPI:1205390069
Name:MOORE, ROSE AMANDA (RADT)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:AMANDA
Last Name:MOORE
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26648 9TH ST APT 245
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-5553
Mailing Address - Country:US
Mailing Address - Phone:424-419-9708
Mailing Address - Fax:
Practice Address - Street 1:2504 W MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90305-2520
Practice Address - Country:US
Practice Address - Phone:323-751-3805
Practice Address - Fax:323-750-5885
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)