Healthcare Provider Details

I. General information

NPI: 1871134601
Provider Name (Legal Business Name): TESS AMELIA MOORE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 OFFICE COURT DR STE 603
SANTA FE NM
87507-4905
US

IV. Provider business mailing address

2221 RIO GRANDE BLVD NW
ALBUQUERQUE NM
87104-2529
US

V. Phone/Fax

Practice location:
  • Phone: 505-310-4764
  • Fax:
Mailing address:
  • Phone: 505-830-1871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-11309
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: