=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447502646
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEREE RENEE MOORE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2012
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3120 HERRIOTT AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94619-2625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-930-1085
-----------------------------------------------------
Fax | 341-946-6172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 19051
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94619-0051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-593-0108
-----------------------------------------------------
Fax | 341-946-6172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 82316
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------