Provider Demographics
NPI:1578857801
Name:MOORE, ALLYSON GAYLE (MS, BCBA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:ALLYSON
Middle Name:GAYLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, BCBA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94942-0189
Mailing Address - Country:US
Mailing Address - Phone:510-331-8490
Mailing Address - Fax:
Practice Address - Street 1:120 PERALTA AVE
Practice Address - Street 2:
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-3519
Practice Address - Country:US
Practice Address - Phone:510-331-8490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-04-2053103K00000X
CA48029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist