Healthcare Provider Details

I. General information

NPI: 1467881961
Provider Name (Legal Business Name): KANESHA MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8295 TOURNAMENT DR STE 150
MEMPHIS TN
38125-8900
US

IV. Provider business mailing address

8295 TOURNAMENT DR STE 150
MEMPHIS TN
38125-8900
US

V. Phone/Fax

Practice location:
  • Phone: 866-563-7772
  • Fax: 901-255-0758
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: