Provider Demographics
NPI:1144358631
Name:MOORE, MARIELE ANN (PHD)
Entity type:Individual
Prefix:MS
First Name:MARIELE
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 LAS ENCINAS DR
Mailing Address - Street 2:
Mailing Address - City:LOS OSOS
Mailing Address - State:CA
Mailing Address - Zip Code:93402-4502
Mailing Address - Country:US
Mailing Address - Phone:805-528-3782
Mailing Address - Fax:
Practice Address - Street 1:1416 LAS ENCINAS DR
Practice Address - Street 2:
Practice Address - City:LOS OSOS
Practice Address - State:CA
Practice Address - Zip Code:93402-4502
Practice Address - Country:US
Practice Address - Phone:805-528-3782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11506103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP11506OtherPSYCHOLOGIST