Basic Information
| Provider Information | |||||||||
| NPI: | 1033518071 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 47TH AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165014378 | ||||||||
| FaxNumber: | 5105694589 | ||||||||
| Practice Location | |||||||||
| Address1: | 4600 47TH AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958243923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169407094 | ||||||||
| FaxNumber: | 5105694589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2014 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.