Provider Demographics
NPI:1063198018
Name:MOORE, MONIQUE SAMANTHA
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:SAMANTHA
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:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32041-0655
Mailing Address - Country:US
Mailing Address - Phone:904-468-7731
Mailing Address - Fax:904-875-5088
Practice Address - Street 1:PO BOX 655
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32041-0655
Practice Address - Country:US
Practice Address - Phone:904-468-7731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22706101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health