Provider Demographics
NPI:1386491702
Name:MOORE, DENISHA TAHEEMA
Entity type:Individual
Prefix:
First Name:DENISHA
Middle Name:TAHEEMA
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 1:4089 PINE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:PORT GIBSON
Mailing Address - State:MS
Mailing Address - Zip Code:39150-3021
Mailing Address - Country:US
Mailing Address - Phone:601-831-4719
Mailing Address - Fax:
Practice Address - Street 1:4089 PINE GROVE RD
Practice Address - Street 2:
Practice Address - City:PORT GIBSON
Practice Address - State:MS
Practice Address - Zip Code:39150-3021
Practice Address - Country:US
Practice Address - Phone:601-831-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker