Provider Demographics
NPI:1396008330
Name:MOORE, DAWN M
Entity Type:Individual
Prefix:MISS
First Name:DAWN
Middle Name:M
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 1:235 W 5TH AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4877
Mailing Address - Country:US
Mailing Address - Phone:619-740-1721
Mailing Address - Fax:760-466-1558
Practice Address - Street 1:235 W 5TH AVE STE 130
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4877
Practice Address - Country:US
Practice Address - Phone:619-740-1721
Practice Address - Fax:760-466-1558
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107563106H00000X
225400000X, 390200000X
CA136684106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program