Provider Demographics
NPI:1144508417
Name:MOORE, BRENDA L
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:L
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 1:524 N DAVIS AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-4860
Mailing Address - Country:US
Mailing Address - Phone:405-787-9794
Mailing Address - Fax:
Practice Address - Street 1:7777 E US HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-9125
Practice Address - Country:US
Practice Address - Phone:405-422-8822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health