Provider Demographics
NPI:1285346387
Name:MOTEN, SHAMORRA T
Entity type:Individual
Prefix:MS
First Name:SHAMORRA
Middle Name:T
Last Name:MOTEN
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 1:4061 SUZANNE DR # CD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-3735
Mailing Address - Country:US
Mailing Address - Phone:228-396-4434
Mailing Address - Fax:228-396-4438
Practice Address - Street 1:4061 SUZANNE DR # CD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-3735
Practice Address - Country:US
Practice Address - Phone:228-396-4434
Practice Address - Fax:228-396-4438
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS22249379Medicaid