Provider Demographics
NPI:1043845092
Name:MOORE, SHANICE KAITLYN JAYE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:KAITLYN JAYE
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 1:1600 WEEOT WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4734
Mailing Address - Country:US
Mailing Address - Phone:707-825-5000
Mailing Address - Fax:
Practice Address - Street 1:2298 NORRIS AVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-9344
Practice Address - Country:US
Practice Address - Phone:707-464-2919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15527-RAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)