Provider Demographics
NPI:1801171442
Name:MOORE, TATIANA M (MFT)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 924
Mailing Address - Street 2:
Mailing Address - City:PAUMA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92061-0924
Mailing Address - Country:US
Mailing Address - Phone:760-271-2629
Mailing Address - Fax:
Practice Address - Street 1:4002 PARK BLVD STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2600
Practice Address - Country:US
Practice Address - Phone:760-271-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-14
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53451106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist