Provider Demographics
NPI:1265507503
Name:MOORE, DEBRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 COYLE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0429
Mailing Address - Country:US
Mailing Address - Phone:916-344-0900
Mailing Address - Fax:
Practice Address - Street 1:5900 COYLE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0429
Practice Address - Country:US
Practice Address - Phone:916-344-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8578103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOPL85783Medicare UPIN