Provider Demographics
NPI:1245595115
Name:MOORE, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3705 SW 27TH ST APT 827
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-7021
Mailing Address - Country:US
Mailing Address - Phone:352-246-4716
Mailing Address - Fax:
Practice Address - Street 1:4131 NW 28TH LN STE 3A
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-6665
Practice Address - Country:US
Practice Address - Phone:352-374-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool