Provider Demographics
NPI:1447745567
Name:MOORE, TANZANIA MALA
Entity Type:Individual
Prefix:
First Name:TANZANIA
Middle Name:MALA
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 1:234 BAUGH ST
Mailing Address - Street 2:
Mailing Address - City:PEARL
Mailing Address - State:MS
Mailing Address - Zip Code:39208-4103
Mailing Address - Country:US
Mailing Address - Phone:769-572-5548
Mailing Address - Fax:
Practice Address - Street 1:3530 MANOR DR STE 5A
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5625
Practice Address - Country:US
Practice Address - Phone:601-738-5260
Practice Address - Fax:601-738-5361
Is Sole Proprietor?:No
Enumeration Date:2018-06-30
Last Update Date:2018-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health