MEDICARE: SHANICE KAITLYN JAYE MOORE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	15527-RAC	CA

General Provider Information

NPI Number	:	1043845092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANICE KAITLYN JAYE MOORE

Provider Business Mailing Address
First Line	:	1600 WEEOT WAY
Second Line	:
City	:	ARCATA
State	:	CA
Zip	:	95521-4734
Country	:	US
Telephone Number	:	707-825-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2298 NORRIS AVE
Second Line	:
City	:	CRESCENT CITY
State	:	CA
Zip	:	95531-9344
Country	:	US
Telephone Number	:	707-464-2919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	03/06/2024

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