Provider Demographics
NPI:1689553067
Name:MOORE, DEEANNA DEAN
Entity type:Individual
Prefix:
First Name:DEEANNA
Middle Name:DEAN
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 1:2320 15TH AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-3902
Mailing Address - Country:US
Mailing Address - Phone:325-245-3557
Mailing Address - Fax:
Practice Address - Street 1:1010 E ROSE ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2016
Practice Address - Country:US
Practice Address - Phone:863-519-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty