Healthcare Provider Details

I. General information

NPI: 1437762929
Provider Name (Legal Business Name): ED TANIQUA CAPRICE MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 DIAMOND BLVD STE 500
CONCORD CA
94520-5719
US

IV. Provider business mailing address

1306 AMBERIDGE CT
ANTIOCH CA
94531-8075
US

V. Phone/Fax

Practice location:
  • Phone: 925-483-2223
  • Fax: 925-826-5878
Mailing address:
  • Phone: 510-230-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: