Provider Demographics
NPI:1245370360
Name:MOORE, DIANA (LMFT, LMHC)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMFT, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 S CALHOUN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46807-1402
Mailing Address - Country:US
Mailing Address - Phone:260-744-4326
Mailing Address - Fax:260-744-0188
Practice Address - Street 1:2712 S CALHOUN ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46807-1402
Practice Address - Country:US
Practice Address - Phone:260-744-4326
Practice Address - Fax:260-744-0188
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000338A101YM0800X
IN35001380A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist