Provider Demographics
NPI:1871799957
Name:MOORE, MARY E (PHD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:MOORE
Other - Last Name:VAKLEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:325 W HOSPITALITY LANE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SAN BERNANDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3212
Mailing Address - Country:US
Mailing Address - Phone:909-386-5500
Mailing Address - Fax:909-386-5520
Practice Address - Street 1:325 W HOSPITALITY LANE
Practice Address - Street 2:SUITE 310
Practice Address - City:SAN BERNANDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3212
Practice Address - Country:US
Practice Address - Phone:909-386-5500
Practice Address - Fax:909-386-5520
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10159103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist