Provider Demographics
NPI:1770826687
Name:MOORE, KATHLEEN L (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:L
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 1:417 S IRENA AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3819
Mailing Address - Country:US
Mailing Address - Phone:310-540-7342
Mailing Address - Fax:
Practice Address - Street 1:417 S IRENA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3819
Practice Address - Country:US
Practice Address - Phone:310-540-7342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17739103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist