Provider Demographics
NPI:1467805150
Name:MOORE, ADAM M
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 BOBWHITE LN
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1406
Mailing Address - Country:US
Mailing Address - Phone:619-432-5042
Mailing Address - Fax:
Practice Address - Street 1:3020 CHILDRENS WAY # MC5100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4223
Practice Address - Country:US
Practice Address - Phone:858-576-1700
Practice Address - Fax:619-795-1228
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA115578106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program