Provider Demographics
NPI:1972939346
Name:MOORE, ELAINE (PHD FT)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD FT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 N LAMER ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504-1625
Mailing Address - Country:US
Mailing Address - Phone:818-599-9765
Mailing Address - Fax:
Practice Address - Street 1:3050 N LAMER ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504-1625
Practice Address - Country:US
Practice Address - Phone:818-599-9765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-17
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC11884106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC11884OtherLICENSE NUMBER