MEDICARE: CHERMAYNE CHANTEL MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	101YM0800X	Mental Health Counselor	124414	CA
4	106H00000X	Marriage & Family Therapist	152655	CA

General Provider Information

NPI Number	:	1700396850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERMAYNE CHANTEL MOORE

Provider Business Mailing Address
First Line	:	1803 W MARCH LN STE C
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6414
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1803 W MARCH LN
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6458
Country	:	US
Telephone Number	:	209-636-5353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2017
Last Update Date	:	01/17/2025

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Directions to “ CHERMAYNE CHANTEL MOORE ” Practice Location

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