Provider Demographics
NPI:1225787096
Name:MOORE, CORRISHA SHANEE
Entity Type:Individual
Prefix:
First Name:CORRISHA
Middle Name:SHANEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CORRISHA
Other - Middle Name:SHANEE
Other - Last Name:CALVERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8716 E 72ND PL APT 205
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-3181
Mailing Address - Country:US
Mailing Address - Phone:918-262-0278
Mailing Address - Fax:
Practice Address - Street 1:1728 S CARSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4610
Practice Address - Country:US
Practice Address - Phone:918-406-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-21
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator