Provider Demographics
NPI:1407106503
Name:MOORE, DEBORAH CHANTAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:CHANTAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17243 HIGHLAND AVE
Practice Address - Street 2:5A
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2847
Practice Address - Country:US
Practice Address - Phone:718-510-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-15
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000229106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist