Basic Information
| Provider Information | |||||||||
| NPI: | 1447600085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10776 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923999630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097970114 | ||||||||
| FaxNumber: | 9097902148 | ||||||||
| Practice Location | |||||||||
| Address1: | 10776 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923999630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097970114 | ||||||||
| FaxNumber: | 9097902148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2016 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF91033 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | LMFT119605 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.