Provider Demographics
NPI:1891388906
Name:MOORE, LASTESHA
Entity Type:Individual
Prefix:
First Name:LASTESHA
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 1:5543 EDMONDSON PIKE STE 106
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37211-5808
Mailing Address - Country:US
Mailing Address - Phone:479-601-7700
Mailing Address - Fax:615-523-2900
Practice Address - Street 1:5543 EDMONDSON PIKE
Practice Address - Street 2:SUITE 106
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211
Practice Address - Country:US
Practice Address - Phone:479-601-7700
Practice Address - Fax:615-523-2900
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
93939393OtherNA