Provider Demographics
NPI:1538732334
Name:MOORE, LATRESSA AALIYAH
Entity type:Individual
Prefix:
First Name:LATRESSA
Middle Name:AALIYAH
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 1:158 PAPER MILL RD APT 9208
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5354
Mailing Address - Country:US
Mailing Address - Phone:229-225-8711
Mailing Address - Fax:
Practice Address - Street 1:120 E TRINITY PL
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3302
Practice Address - Country:US
Practice Address - Phone:404-378-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker