Provider Demographics
NPI:1356677108
Name:MOORE, STAN ROBERT (PHD)
Entity Type:Individual
Prefix:DR
First Name:STAN
Middle Name:ROBERT
Last Name:MOORE
Suffix:
Gender:M
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92074-0549
Mailing Address - Country:US
Mailing Address - Phone:619-464-1165
Mailing Address - Fax:619-464-1157
Practice Address - Street 1:530 LOMAS SANTA FE DR
Practice Address - Street 2:SUITE M
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1349
Practice Address - Country:US
Practice Address - Phone:619-464-1165
Practice Address - Fax:619-464-1157
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14910103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical