Healthcare Provider Details

I. General information

NPI: 1609431683
Provider Name (Legal Business Name): DIARRA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18288 N US HIGHWAY 41
LUTZ FL
33549-4400
US

IV. Provider business mailing address

417 COMMERCIAL CT STE C
VENICE FL
34292-1655
US

V. Phone/Fax

Practice location:
  • Phone: 813-527-9638
  • Fax: 813-867-7728
Mailing address:
  • Phone: 800-356-4049
  • 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: