Provider Demographics
NPI:1831734854
Name:MORELAND, SHANTE
Entity type:Individual
Prefix:
First Name:SHANTE
Middle Name:
Last Name:MORELAND
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 1:539 S CHESTNUT ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901-4885
Mailing Address - Country:US
Mailing Address - Phone:281-706-1266
Mailing Address - Fax:
Practice Address - Street 1:23935 BEAVERWOOD DR
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-5804
Practice Address - Country:US
Practice Address - Phone:936-632-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27-2978377Medicaid