Provider Demographics
NPI:1144983198
Name:MOORE, DOMINIQUE EUNICE (LLC)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:EUNICE
Last Name:MOORE
Suffix:
Gender:F
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26545 AMERICAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-6115
Mailing Address - Country:US
Mailing Address - Phone:800-395-3223
Mailing Address - Fax:
Practice Address - Street 1:8150 OLD 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8700
Practice Address - Country:US
Practice Address - Phone:800-395-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451024307101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional