Provider Demographics
NPI:1215050448
Name:MOORE, RENEE Y (PSYD)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:Y
Last Name:MOORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 RIVERCHASE OFFICE PLZ STE 115
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-2810
Mailing Address - Country:US
Mailing Address - Phone:205-403-0955
Mailing Address - Fax:
Practice Address - Street 1:2 RIVERCHASE OFFICE PLZ STE 115
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-2810
Practice Address - Country:US
Practice Address - Phone:205-403-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1968101YP2500X
AL1785103T00000X
MD04789103T00000X
DCPSY1000811103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410230400Medicaid
MD614SOtherMEDICARE PTAN