Provider Demographics
NPI:1720707193
Name:ALONZO MOORE, TIFFANY ALEXANDRIA (AMFT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ALEXANDRIA
Last Name:ALONZO MOORE
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 GEORGETOWN PL STE A3
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6228
Mailing Address - Country:US
Mailing Address - Phone:209-429-0377
Mailing Address - Fax:
Practice Address - Street 1:4545 GEORGETOWN PL STE A3
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6228
Practice Address - Country:US
Practice Address - Phone:209-429-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT132956101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor