Healthcare Provider Details

I. General information

NPI: 1245754928
Provider Name (Legal Business Name): LEANDRE MOORE III LLBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 RUSSELL ST
DETROIT MI
48207-4825
US

IV. Provider business mailing address

19319 SNOWDEN ST
DETROIT MI
48235-1261
US

V. Phone/Fax

Practice location:
  • Phone: 313-396-5300
  • Fax:
Mailing address:
  • Phone: 313-334-8148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: