Provider Demographics
NPI:1932426723
Name:MOORE, BRENNA E (BA)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:E
Last Name:MOORE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 W 3RD
Mailing Address - Street 2:
Mailing Address - City:RAVIA
Mailing Address - State:OK
Mailing Address - Zip Code:73455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4216 COMMERCIAL LN
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-7785
Practice Address - Country:US
Practice Address - Phone:580-924-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor