Provider Demographics
NPI:1235721945
Name:MOORE, DASHA MARIE
Entity Type:Individual
Prefix:
First Name:DASHA
Middle Name:MARIE
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 1:17 EL CAMINO CORTO
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-5409
Mailing Address - Country:US
Mailing Address - Phone:925-708-9691
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1188
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:519-251-8120
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician