Provider Demographics
NPI:1144829037
Name:MOORE, DAMON
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25898 CHIPPENDALE CT APT A
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3975
Mailing Address - Country:US
Mailing Address - Phone:810-937-9137
Mailing Address - Fax:
Practice Address - Street 1:15450 E JEFFERSON AVE STE 180
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-2031
Practice Address - Country:US
Practice Address - Phone:313-444-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIPP0000001037037103TS0200X
MI6362009236103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool