Provider Demographics
NPI:1093199531
Name:MOORE, TYANNA
Entity Type:Individual
Prefix:
First Name:TYANNA
Middle Name:
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 1:28074 GLASGOW ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2904
Mailing Address - Country:US
Mailing Address - Phone:248-497-1159
Mailing Address - Fax:
Practice Address - Street 1:28074 GLASGOW ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2904
Practice Address - Country:US
Practice Address - Phone:248-497-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
TX3005103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other