Provider Demographics
NPI:1043526171
Name:MOORE, JUDY
Entity type:Individual
Prefix:
First Name:JUDY
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 1:2100 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-6591
Mailing Address - Country:US
Mailing Address - Phone:530-747-3400
Mailing Address - Fax:530-753-0398
Practice Address - Street 1:2100 5TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-6591
Practice Address - Country:US
Practice Address - Phone:530-747-3400
Practice Address - Fax:530-753-0398
Is Sole Proprietor?:No
Enumeration Date:2010-08-26
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46735106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist