Provider Demographics
NPI:1104944792
Name:MOORE, ETHEL FAY (CPRP)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:FAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14575 STONECRESS ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43423 DIVISION ST STE 107
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93535-4640
Practice Address - Country:US
Practice Address - Phone:661-726-2850
Practice Address - Fax:661-726-2854
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA171M00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner