Healthcare Provider Details

I. General information

NPI: 1033968474
Provider Name (Legal Business Name): TIANNA RAQUEL MOORE MHC-LP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 NOSTRAND AVE
BROOKLYN NY
11226-6456
US

IV. Provider business mailing address

PO BOX 1342
VALLEY STREAM NY
11582-1342
US

V. Phone/Fax

Practice location:
  • Phone: 347-973-3119
  • Fax:
Mailing address:
  • Phone: 347-998-0824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number017810
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: