Provider Demographics
NPI:1720559248
Name:MOORE, KATHLEEN M (PSYD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 CATTAIL CT
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-5094
Mailing Address - Country:US
Mailing Address - Phone:208-920-1750
Mailing Address - Fax:
Practice Address - Street 1:918 CATTAIL CT
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5094
Practice Address - Country:US
Practice Address - Phone:208-920-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY-14596103T00000X
IDPSY-203097103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist