Healthcare Provider Details

I. General information

NPI: 1558819854
Provider Name (Legal Business Name): COURTNEY MOORE CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1837 RYAN AVE NW
GRAND RAPIDS MI
49534-2239
US

IV. Provider business mailing address

1837 RYAN AVE NW
GRAND RAPIDS MI
49534-2239
US

V. Phone/Fax

Practice location:
  • Phone: 616-520-7183
  • Fax:
Mailing address:
  • Phone: 616-520-7183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number63262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: