Provider Demographics
NPI:1386095453
Name:MOORE, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12641
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-2641
Mailing Address - Country:US
Mailing Address - Phone:858-453-8509
Mailing Address - Fax:858-453-8509
Practice Address - Street 1:480 ALTA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92179-0001
Practice Address - Country:US
Practice Address - Phone:619-661-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20947103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical