Provider Demographics
NPI:1295018034
Name:PENN MOORE, TANISHA (LADC)
Entity Type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:PENN MOORE
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1101
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74101-1101
Mailing Address - Country:US
Mailing Address - Phone:918-245-0231
Mailing Address - Fax:918-241-5031
Practice Address - Street 1:2727 S 137TH WEST AVE
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-5017
Practice Address - Country:US
Practice Address - Phone:918-245-0231
Practice Address - Fax:918-241-5031
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)