Provider Demographics
NPI:1750020368
Name:MOOREHEAD, OTERRIOUS L
Entity Type:Individual
Prefix:
First Name:OTERRIOUS
Middle Name:L
Last Name:MOOREHEAD
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 1:4744 WE ROSS PKWY APT 52-104
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7007
Mailing Address - Country:US
Mailing Address - Phone:601-622-0555
Mailing Address - Fax:
Practice Address - Street 1:4744 WE ROSS PKWY APT 52-104
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7007
Practice Address - Country:US
Practice Address - Phone:601-622-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRBT-21-175696106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician