Basic Information
| Provider Information | |||||||||
| NPI: | 1124771662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | JOSSELYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BA PSYCHOLOGY | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6300 | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923256300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093363330 | ||||||||
| FaxNumber: | 9513004719 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 CA-138 | ||||||||
| Address2: | |||||||||
| City: | CRESTLINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923256300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093363330 | ||||||||
| FaxNumber: | 9513004719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2022 | ||||||||
| LastUpdateDate: | 10/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.