Provider Demographics
NPI:1720074370
Name:MOORE, URSULA SUSANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:URSULA
Middle Name:SUSANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 JOSINA AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-2716
Mailing Address - Country:US
Mailing Address - Phone:650-494-9125
Mailing Address - Fax:650-494-9125
Practice Address - Street 1:703 WELCH RD
Practice Address - Street 2:SUITE F6
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1710
Practice Address - Country:US
Practice Address - Phone:650-494-9125
Practice Address - Fax:650-494-9125
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALS002545103T00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ49518ZMedicare ID - Type Unspecified