Provider Demographics
NPI:1518042753
Name:MOORE, BRIAN LEOPOLD (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEOPOLD
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 1:7621 CANOGA AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-4912
Mailing Address - Country:US
Mailing Address - Phone:818-642-1269
Mailing Address - Fax:818-598-6977
Practice Address - Street 1:7621 CANOGA AVE
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-4912
Practice Address - Country:US
Practice Address - Phone:818-642-1269
Practice Address - Fax:818-598-6937
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13499103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GD050ZOtherPTAN
GD050YOtherPTAN
GD050YOtherPTAN