Provider Demographics
NPI:1669598215
Name:MOORE, KIMBERLY DIANE
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DIANE
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 1:11300 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90304-2800
Mailing Address - Country:US
Mailing Address - Phone:323-252-4610
Mailing Address - Fax:
Practice Address - Street 1:6838 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7008
Practice Address - Country:US
Practice Address - Phone:323-252-4610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health