Provider Demographics
NPI:1376847871
Name:MOORE, INGRID MARIA (MS)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:MARIA
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 SOUTH HOLLY STREET
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501
Mailing Address - Country:US
Mailing Address - Phone:541-774-8200
Mailing Address - Fax:541-774-7964
Practice Address - Street 1:140 SOUTH HOLLY STREET
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501
Practice Address - Country:US
Practice Address - Phone:541-774-8200
Practice Address - Fax:541-774-7964
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional