Provider Demographics
NPI:1366456048
Name:MOORE, TIFFANY ANNETTE (MA)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:ANNETTE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 PLEASANT MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2672
Mailing Address - Country:US
Mailing Address - Phone:636-344-6572
Mailing Address - Fax:
Practice Address - Street 1:5 W PEARCE BLVD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-1415
Practice Address - Country:US
Practice Address - Phone:636-344-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003019174101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health