Provider Demographics
NPI:1275675522
Name:MOORE, LINDA LORRAINE (MA)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:LORRAINE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8666 W ROSE GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3411
Mailing Address - Country:US
Mailing Address - Phone:623-362-2534
Mailing Address - Fax:
Practice Address - Street 1:7301 N 58TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-1893
Practice Address - Country:US
Practice Address - Phone:623-842-8148
Practice Address - Fax:623-435-9404
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ581050Medicaid