Basic Information
| Provider Information | |||||||||
| NPI: | 1932440633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4107 AUTUMN VIEW CT | ||||||||
| Address2: | |||||||||
| City: | FENTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484309128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102202787 | ||||||||
| FaxNumber: | 8102202834 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 GRAND RIVER RD | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481147333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102202787 | ||||||||
| FaxNumber: | 8102202834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2013 | ||||||||
| LastUpdateDate: | 06/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801078057 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.