Provider Demographics
NPI:1598220246
Name:MOORE, SHANAY LAMONT
Entity Type:Individual
Prefix:MR
First Name:SHANAY
Middle Name:LAMONT
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30660 MILKY WAY DR APT V174
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3274
Mailing Address - Country:US
Mailing Address - Phone:951-775-3101
Mailing Address - Fax:
Practice Address - Street 1:30660 MILKY WAY DR.
Practice Address - Street 2:V174
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592
Practice Address - Country:US
Practice Address - Phone:951-775-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician