Provider Demographics
NPI:1366874638
Name:MOORE, LOUISE (MFT)
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:LOUISE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 4TH ST STE 13
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3072
Mailing Address - Country:US
Mailing Address - Phone:707-774-1225
Mailing Address - Fax:
Practice Address - Street 1:7 4TH ST STE 13
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3072
Practice Address - Country:US
Practice Address - Phone:707-774-1225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2020-09-23
Deactivation Date:2020-08-12
Deactivation Code:
Reactivation Date:2020-08-26
Provider Licenses
StateLicense IDTaxonomies
CA50623106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist