Provider Demographics
NPI:1003524620
Name:MOORE, ANIYAH NICHELLE
Entity Type:Individual
Prefix:
First Name:ANIYAH
Middle Name:NICHELLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11852 MOUNT VERNON AVE APT 672
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-8329
Mailing Address - Country:US
Mailing Address - Phone:951-390-4323
Mailing Address - Fax:
Practice Address - Street 1:560 E HOSPITALITY LN STE 400
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3545
Practice Address - Country:US
Practice Address - Phone:909-891-1599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician