Basic Information
| Provider Information | |||||||||
| NPI: | 1366165540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE-GRANT | ||||||||
| FirstName: | DEJA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOORE-GRANT | ||||||||
| OtherFirstName: | DEJA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3008 LAWTON ST APT 3A | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482162301 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2939 RUSSELL ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482074825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2022 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 6451022348 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.