Provider Demographics
NPI:1780686857
Name:GEPHART MOORE, ANNE A (PSY D)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:A
Last Name:GEPHART MOORE
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 NERGE RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-2972
Mailing Address - Country:US
Mailing Address - Phone:847-333-7750
Mailing Address - Fax:
Practice Address - Street 1:1940 NERGE RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-2972
Practice Address - Country:US
Practice Address - Phone:847-333-7750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071005936103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL574550Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER