Provider Demographics
NPI:1659495240
Name:MOORE, MELVIN MEDERO JR (PHD)
Entity type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:MEDERO
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17649 CRABAPPLE WAY
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-7461
Mailing Address - Country:US
Mailing Address - Phone:310-632-9168
Mailing Address - Fax:310-342-3955
Practice Address - Street 1:17649 CRABAPPLE WAY
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-7461
Practice Address - Country:US
Practice Address - Phone:310-632-9168
Practice Address - Fax:310-342-3955
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11086103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical