Provider Demographics
NPI:1386903755
Name:MOORE, LAURIE ALISON (MA, LMFT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ALISON
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 LIONS FIELD DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-9736
Mailing Address - Country:US
Mailing Address - Phone:831-477-7007
Mailing Address - Fax:832-575-7007
Practice Address - Street 1:65 LIONS FIELD DR
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-9736
Practice Address - Country:US
Practice Address - Phone:831-477-7007
Practice Address - Fax:832-575-7007
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-04
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36950106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFT369500OtherBLUE SHIELD