Provider Demographics
NPI:1760833594
Name:MOORE, DIANE LYNN (MA, LMFT)
Entity Type:Individual
Prefix:MS
First Name:DIANE
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, 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 3534
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95063-3534
Mailing Address - Country:US
Mailing Address - Phone:408-454-8088
Mailing Address - Fax:
Practice Address - Street 1:155 E CAMPBELL AVE STE 125
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2059
Practice Address - Country:US
Practice Address - Phone:408-454-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-22
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122248106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist