Provider Demographics
NPI:1992201917
Name:MOORER, KAYLA D (PHD, LP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:D
Last Name:MOORER
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3708
Mailing Address - Country:US
Mailing Address - Phone:601-580-5453
Mailing Address - Fax:
Practice Address - Street 1:1330 PAGE DR S STE 102A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3562
Practice Address - Country:US
Practice Address - Phone:701-478-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2949103TC1900X, 103TH0100X, 103TC1900X, 103TH0100X
ND564103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1476477Medicaid