Provider Demographics
NPI:1710139720
Name:MOORE, TRACIE (PHD)
Entity Type:Individual
Prefix:MS
First Name:TRACIE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22569 MIDDLE CAMP RD
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9681
Mailing Address - Country:US
Mailing Address - Phone:209-586-3707
Mailing Address - Fax:209-586-3707
Practice Address - Street 1:22569 MIDDLE CAMP RD
Practice Address - Street 2:
Practice Address - City:TWAIN HARTE
Practice Address - State:CA
Practice Address - Zip Code:95383-9681
Practice Address - Country:US
Practice Address - Phone:209-586-3707
Practice Address - Fax:209-586-3707
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12107103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical