Provider Demographics
NPI:1225032865
Name:MOORE, STEPHANIE (PSYD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24992 KATIE AVE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92053
Mailing Address - Country:US
Mailing Address - Phone:949-280-7984
Mailing Address - Fax:949-474-1174
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:#603
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-731-6231
Practice Address - Fax:714-731-6283
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2010-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14222103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY14222OtherLICENSE
CACP14222BMedicare UPIN