Basic Information
| Provider Information | |||||||||
| NPI: | 1730372483 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | KINDRA | ||||||||
| MiddleName: | DENISE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW #84940, CADC-II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 995 GATEWAY CENTER WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 995 GATEWAY CENTER WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6193982156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2007 | ||||||||
| LastUpdateDate: | 10/11/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | ASW63448 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 84940 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.