Basic Information
| Provider Information | |||||||||
| NPI: | 1710330097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | G3500 FLUSHING RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485044238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102499924 | ||||||||
| FaxNumber: | 8102499927 | ||||||||
| Practice Location | |||||||||
| Address1: | G3500 FLUSHING RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485044238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102499924 | ||||||||
| FaxNumber: | 8102499927 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 07/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.