Healthcare Provider Details

I. General information

NPI: 1063225167
Provider Name (Legal Business Name): BRENA'SHA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BRIDGEPORT AVE UNIT 405
SHELTON CT
06484-4660
US

IV. Provider business mailing address

333 VINCELLETTE ST UNIT 80
BRIDGEPORT CT
06606-2235
US

V. Phone/Fax

Practice location:
  • Phone: 203-993-6592
  • Fax:
Mailing address:
  • Phone: 203-993-9329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: