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General NPI Number Information
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NPI Number | 1447745567
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Entity Type | Individual
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Provider Name | TANZANIA MALA MOORE
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Gender | Female
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Dates
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Enumeration Date | 06/30/2018
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Last Update Date | 06/30/2018
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Provider Practice Location Address
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Address Line | 3530 MANOR DR STE 5A
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City | VICKSBURG
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State | MS
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Zip | 39180-5625
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Country | US
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Telephone | 601-738-5260
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Fax | 601-738-5361
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Provider Business Mailing Address
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Address Line | 234 BAUGH ST
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City | PEARL
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State | MS
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Zip | 39208-4103
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Country | US
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Telephone | 769-572-5548
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | MS
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