Provider Demographics
NPI:1619179413
Name:MOORE, LA TONYA CRYSTAL-KELLY (MHRS)
Entity Type:Individual
Prefix:MS
First Name:LA TONYA
Middle Name:CRYSTAL-KELLY
Last Name:MOORE
Suffix:
Gender:F
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 BELLA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-4038
Mailing Address - Country:US
Mailing Address - Phone:510-472-8146
Mailing Address - Fax:
Practice Address - Street 1:421 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5534
Practice Address - Country:US
Practice Address - Phone:510-839-3769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health