Provider Demographics
NPI:1710424015
Name:MOOREHEAD, ANTOINETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:MOOREHEAD
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 1:2866 SOMERSET PARK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3281
Mailing Address - Country:US
Mailing Address - Phone:813-951-4367
Mailing Address - Fax:
Practice Address - Street 1:2866 SOMERSET PARK DR APT 103
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3281
Practice Address - Country:US
Practice Address - Phone:813-951-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65406Medicaid