Provider Demographics
NPI:1710576368
Name:MOORE, ANN R (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 E SUMMER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-8201
Mailing Address - Country:US
Mailing Address - Phone:812-320-3938
Mailing Address - Fax:
Practice Address - Street 1:2526 E SUMMER CREEK DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-8201
Practice Address - Country:US
Practice Address - Phone:812-320-3938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041122A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist