Provider Demographics
NPI:1063446169
Name:MOORE, SUSAN MOONS (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:MOONS
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 1:2200 BERGQUIST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LACKLAND AFB
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5300
Mailing Address - Country:US
Mailing Address - Phone:210-292-6707
Mailing Address - Fax:
Practice Address - Street 1:7010 W HIGHWAY 71
Practice Address - Street 2:SUITE 340-143
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8300
Practice Address - Country:US
Practice Address - Phone:512-301-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31396103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical