Provider Demographics
NPI:1720951635
Name:MOORE, LAKISHA
Entity type:Individual
Prefix:
First Name:LAKISHA
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 1:12530 FAIRWOOD PKWY STE 102-1126
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-6356
Mailing Address - Country:US
Mailing Address - Phone:410-995-8388
Mailing Address - Fax:
Practice Address - Street 1:12530 FAIRWOOD PKWY STE 102-1126
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-6356
Practice Address - Country:US
Practice Address - Phone:410-995-8388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician