Provider Demographics
NPI:1447600085
Name:MOORE, SAMUEL EVAN (MS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:EVAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10776 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-9630
Mailing Address - Country:US
Mailing Address - Phone:909-797-0114
Mailing Address - Fax:909-790-2148
Practice Address - Street 1:10776 FREMONT ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-9630
Practice Address - Country:US
Practice Address - Phone:909-797-0114
Practice Address - Fax:909-790-2148
Is Sole Proprietor?:No
Enumeration Date:2016-06-14
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF91033106H00000X
CALMFT119605106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist