Provider Demographics
NPI:1639211493
Name:MOORE, MARIE C (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:C
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MS
Other - First Name:MARIE
Other - Middle Name:O
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1145 GAYLEY AVE
Mailing Address - Street 2:SUITE 322
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3423
Mailing Address - Country:US
Mailing Address - Phone:310-991-5720
Mailing Address - Fax:310-208-0684
Practice Address - Street 1:1145 GAYLEY AVE
Practice Address - Street 2:SUITE 322
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3423
Practice Address - Country:US
Practice Address - Phone:310-991-5720
Practice Address - Fax:310-208-0684
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15404103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY15404OtherLICENSE