Provider Demographics
NPI:1114598802
Name:MOORE, TAITANNA (NCC, APC)
Entity Type:Individual
Prefix:
First Name:TAITANNA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NCC, APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 DALLAS HWY SW STE 240
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-2597
Mailing Address - Country:US
Mailing Address - Phone:470-422-9939
Mailing Address - Fax:
Practice Address - Street 1:2655 DALLAS HWY SW STE 240
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30064-2597
Practice Address - Country:US
Practice Address - Phone:470-422-9939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007678101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional