Provider Demographics
NPI:1841613841
Name:MOORE, BEULAH
Entity Type:Individual
Prefix:
First Name:BEULAH
Middle Name:
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 1:5622 E FOREST ISLE CT APT 83
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70131-8909
Mailing Address - Country:US
Mailing Address - Phone:504-214-2940
Mailing Address - Fax:
Practice Address - Street 1:2439 MANHATTAN BLVD
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058
Practice Address - Country:US
Practice Address - Phone:504-333-6657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5340171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker