Provider Demographics
NPI:1316683600
Name:MOORE, BRYANNA (LAC)
Entity type:Individual
Prefix:
First Name:BRYANNA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2020
Mailing Address - Country:US
Mailing Address - Phone:602-329-8250
Mailing Address - Fax:
Practice Address - Street 1:9014 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-8304
Practice Address - Country:US
Practice Address - Phone:602-230-7373
Practice Address - Fax:602-441-5836
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-19221101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor