Provider Demographics
NPI:1487774592
Name:GRENARD MOORE, SALLY JO (PHD)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JO
Last Name:GRENARD MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JO GRENARD
Other - Last Name:NESBITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10605 SKYFLOWER DRIVE
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-6453
Mailing Address - Country:US
Mailing Address - Phone:512-250-5974
Mailing Address - Fax:512-329-8299
Practice Address - Street 1:2901 BEE CAVES ROAD
Practice Address - Street 2:BOX N
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5571
Practice Address - Country:US
Practice Address - Phone:512-329-8000
Practice Address - Fax:512-329-8299
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23614103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist