Provider Demographics
NPI:1871900373
Name:MOORE, JOHN (MS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N MILFORD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1047
Mailing Address - Country:US
Mailing Address - Phone:248-684-6400
Mailing Address - Fax:
Practice Address - Street 1:1800 N MILFORD RD STE 100
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1047
Practice Address - Country:US
Practice Address - Phone:810-222-9847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011549103T00000X
MI6361004249103TC2200X
MI7401000465103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent