Provider Demographics
NPI:1316535941
Name:MOORE, BREA SHANICE
Entity Type:Individual
Prefix:
First Name:BREA
Middle Name:SHANICE
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 1:14150 GRAND SETTLEMENT BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70818-4326
Mailing Address - Country:US
Mailing Address - Phone:225-270-9263
Mailing Address - Fax:
Practice Address - Street 1:14150 GRAND SETTLEMENT BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70818-4326
Practice Address - Country:US
Practice Address - Phone:225-270-9263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA00000Medicaid