Provider Demographics
NPI:1073300927
Name:MOORE, DESIREE (CCHW)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:CCHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ STE 100
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4752
Mailing Address - Country:US
Mailing Address - Phone:254-338-8602
Mailing Address - Fax:
Practice Address - Street 1:409 S AMY LN APT D
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1598
Practice Address - Country:US
Practice Address - Phone:254-338-8602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-23
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker