Healthcare Provider Details

I. General information

NPI: 1164849147
Provider Name (Legal Business Name): DAVID BRIAN MOORE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 LAKE EASTBROOK BLVD SE SUITE 258
GRAND RAPIDS MI
49546-5938
US

IV. Provider business mailing address

6845 TERRA COTTA DR SE
CALEDONIA MI
49316-8005
US

V. Phone/Fax

Practice location:
  • Phone: 616-719-0194
  • Fax:
Mailing address:
  • Phone: 616-450-1590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085397
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: