Provider Demographics
NPI:1801827118
Name:MOORE, EMILY A (MFT)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 N MARENGO AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-1764
Mailing Address - Country:US
Mailing Address - Phone:626-793-1078
Mailing Address - Fax:626-585-0440
Practice Address - Street 1:95 N MARENGO AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1764
Practice Address - Country:US
Practice Address - Phone:626-793-1078
Practice Address - Fax:626-585-0440
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC33911106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA424383OtherMANAGED CARE CO. ID