Provider Demographics
NPI:1760649628
Name:MOORE, MICHELLE GLYNISE (EARLY INTERVENTION P)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:GLYNISE
Last Name:MOORE
Suffix:
Gender:F
Credentials:EARLY INTERVENTION P
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:GLYNISE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EARLY INTERVENTION P
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406
Mailing Address - Country:US
Mailing Address - Phone:708-698-0714
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 658
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406
Practice Address - Country:US
Practice Address - Phone:708-698-0714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150107720104100000X
IL1490276891041C0700X
IL252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical