Provider Demographics
NPI:1912538661
Name:MOORE, KYLIE MAE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22540 GREEN MOUNT PL
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-2740
Mailing Address - Country:US
Mailing Address - Phone:714-926-3590
Mailing Address - Fax:
Practice Address - Street 1:12395 LEWIS ST STE 202
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4694
Practice Address - Country:US
Practice Address - Phone:714-867-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst